Intraoral Examination

To make a good intraoral examination we have to be familiar with the intraoral structures in order to know which is normal and which is abnormal. For example :we should know the normal variation of buccal mucosa. The last structure we examine in the extraoral examination is the lip(the vermillion border of the lip) so we start from the lips in the intraoral examination .Then labial mucosa and sulcus, buccal mucosa commissure area ,sulcus (vestibule) , gingival ,alveolar ridge (lower jaw and upper jaw), tongue (dorsum surface ,lateral surface and ventral surface. we should evaluate each structure in these surfaces), floor of the mouth and the last structures we examine is the hard and soft palate.
note: this order is the one that we should follow for examination in the clinic to make everything easy for us.

Now when we examine the lip we start with the lower lip , we turned it outside and we palpate for nodules ,tenderness or any masses, then we

examine the labial mucosa and we look for blisters ,ulcers ,traumatic lesions or any abnormality including the vermillion border( applying our knowledge in oral pathology) so we document any abnormalities ,we don't identify them.

Then we examine the sulcus and commissural area and we identify the labial frenum (note that these things that we see it in the lower lip) .we also identify if there is any abnormality like : pigmentation ,masses ,ulceration, erosions(like hematoma which is blue ,purple or red in color) or white lesions. We do the same thing for the upper lip , we identify the labial mucosa and the labial frenum which sometimes has a structure we call it frenal tag.

so the frenal attachment is sometimes broken may be due to trauma in childhood making the frenal tag.

And then you examine labial mucosa and commissural area ,we look at the mucobuccal fold ,assess the color ,contour ,frenum and see if there is any lesion. Now bucccal mucosa , we should remember that there is many normal variations of buccal mucosa and commissural area like : linea alba, leukoedma ( disappears upon stretching), commissural pit , Fordyce granules. We should also know from normal anatomy that the parotid duct opens in the buccal mucosa >> it may be obvious as papilla shape and sometimes we should look for it because it isn't obvious. it is located opposite to maxillary molars. {{pay attention for this structure}} These are the most common variations that we see in buccal mucosa and comissures.

note: there is a difference between hematoma and racial (physiological) pigmentation which are brown in color and don't show any elevation upon palpation . hematoma is localized ,but racial pigmentation will never be focal.
Now we will take about the bimanual palpation ,we use this way to examine the masster muscle and parotid duct orifice by drying the saliva on buccal mucosa then determine the location of the parotid gland and press on it , there will saliva on your finger that is inside the mouth. sometimes we can see small elevation on the labial mucosa ,those are minor salivary glands to palpate them we can use the same method as parotid gland(bimanual palpation. ) After we finish with labial and buccal mucosa and identifying all structures , we move to the gingiva (buccal first, then labial aspects). we start with mandibular gingiva then maxillary gingiva with the same order.

routinely we start with lower right side then upper.

lingualy on the gingiva we can see sometimes mandibular tori on mandibular gingiva and maxillary tori on the palate.

The gingiva includes :attached gingiva and moveable gingiva. we should notice if there is any lesion , erthyma, depression or calculus deposits. if the patient is edentulous we assess the alveolar mucosa or the residual ridge. we assess also the color ,firmness , resorption (sometimes the patient comes and he /she needs a complete denture but when we examine him/her we may find another problem so we refer it to another department) remaining root or any other abnormalities and we document these things in order to help us in the treatment planning. Then we examine the tongue >> remember that we should examine dorsal , lateral(we look posteriorly because it's the most common site for oral cancer) and ventral surface of the tongue. we inspect the dorsum of the tongue for any swellings or ulceration. sometimes we can see white coated tongue in fasting people . we also assess the color , papillae (if they are within normal limit or if there is any area of depapillation ) , the movement of the tongue and the location(we here assess the hypoglossal nerve ). in hairy tongue the filiform papillae are elongated like hair and pigmented. foliate papillae are located on the posterior area of the lateral surface of the tongue. circumvallite papillae are the lowest in number[8-11] and they are located posterioly in the oral cavity , in the other hand filiform papillae are the largest in number and the most prominent and located on the dorsum of the tongue. fungiform are red in color and looks like fungi. foliate papillae are the least prominent . we can see the area of depapillation (hypertrophy) of filiform papillae in geographic tongue >> it's a variation of normal not a disease , it may look like a disease but it's not a disease.

End of part( 1) Done by : Raneem Al-Rashdan

Part -2Done by: Lamees Nimri *How we examine the dorsum of the tongue? We ask the patient to protrude the tongue, we assess the mobility if there is any abnormality and if there is any fasciculation and it is usually present with patient who has hypoglossal nerve palsy or stroke because the patient will have paralysis in the muscle of the tongue *Remember:Fasciculation "muscle twitch" is a small, local, involuntary muscle contraction and relaxation. After we inspected all the papillae on the dorsum of the tongue, we use gauze to hold the tip of the tongue and move it to one side to see the lateral border of it on both the right and left sides and we see if there are any abnormalities like ulceration, white lesions, red lesions, masses, and you might palpate the tongue by bi-digital palpation like in the picture below. We do palpation when we are suspicious because squamous cell carcinoma might be ulcer, white lesion, red lesion or mass.

Foliate papillae is located on the posterior lateral surface of the tongue and they look like folds or grooves( sometimes you can use air to count them because they move when you put air on them). *The picture below represents the types of the papillae on the tongue.

There is lingual tonsil which is located above the foliate papillae as you can see in the picture below, during cold this tonsil may hypertrophied because it's lymphoid tissue. Sometimes may calcified and look like stone in the oral cavity. When we examine the oropharynx we may also found stones on the tonsils.

After we examine the dorsum and the lateral surface of the tongue we rise the tongue to the palate we can see the lingual frenum, pilica sublingularis (it's also called plica fimbriata) and the veins which look very prominent in the elderly and we call them varicosities as show in the picture below.

The arrow in the picture above refers to the pilica sublingularis. The length of the lingual frenum differs from one person to another, some patients have an extremely short lingual frenum they can't protrude their tongue or to rise it to touch the palate this condition is called Ankyloglossia (see the picture below).in these patients we can't examine the ventral surface of the tongue.

And the test we use to know if the patient has ankyloglossia or not we ask them to protrude their tongue and lick their lower lip, if the tongue goes beyond the vermilion border of the lower lip so the patient doesn't have ankyloglossia. This condition needs further management (surgery and excision) to learn the speech.

Now after we finish examining the ventral of the tongue we move to the floor of the mouth, we should notice the orifices of the submandibular glad Warton's Duct and they look like papillae on both sides of the lingual frenum as you can see on the picture below. Sometimes we may find stones in the ducts of the salivary gland.

We also check if there is any abnormality in the floor of the mouth or any masses and lesions. The sublingual glad opens in more than one orifice and they aren't prominent like the submandibular duct orifices. jfj The excretory ducts of the sublingual gland are from eight to twenty in number. some join the submandibular duct; others open separately into the mouth, One or more join to form the major sublingual duct (larger sublingual duct, duct of Bartholin), which opens into the submandibular duct.(wiki) After that, we do bimanual palpation to the floor of the mouth to see if there are palpable masses

By doing bimanual palpation to the floor of the mouth we can distinguish between submandibular gland and lymph nodes if it's small (pea size) then its lymph node if it's big we should think of submandibular gland.

*After that, we examine the hard and soft palate:In the hard palate we should notice the incisive papilla between the central incisors, and the rugae area (folds on the anterior hard palate) and we also notice the midline raphe in the midline of the palate, and the tuberosities we also examine them. We also examine all the mucosa to see if there is any abnormality and the junction between the hard and soft palate.

Sometimes we have to use two mirrors to perform the examination specially when there are areas that are difficult to see like the area between the tuberosity and the buccal mucosa and the posterior part of the lateral tongue.

Soft palatewe depress the tongue by this we examine the vagus nerve (because it supplies soft palate and one of the tongue muscles) and we examine the uvula if it's located in the midline or there's any deviation.

Soft palate should be inspected specially in heavy smokers because they may have oral cancer. And hard palate should be examined in pipe smokers because they might have nicotinic stomatitis as shown in the picture below

we ask the patient to say "Ah" and we look at the uvula and the soft palate and we notice also the tonsils if there are any calcifications which are called tonsilloliths they give bad odor to the mouth " halitosis" ,if they are enlarged or inflamed. Enlarged Tonsillitis Hard(stones)Tonsilloliths Some patient may have bifurcated uvula which is a variation of normal and some they have bifurcated tongue as well.

In patients with Jaundice we can see it in the ventral of the tongue and the junction between hard and soft palate" soft palate mainly". When we examine the hard palate we may find torus palatinus, and if this patient wants to make a denture we should refer him to the surgery. -Which muscles are examined intraorally? Lateral and medial pterygoid muscle. Medial pterygoid we put our finger on the medial surface of the ramus and this causes discomfort to the patient and this make confusion to the examiner whether it's a pain in the muscle or a discomfort due to putting the finger on it. Lateral pterygoid put the finger on the tuberosity area, it's also annoying and painful and it's not reliable. While we are examining the tongue, mucosa and the ducts of the salivary glands we also assess the adequacy of the saliva, patients with not enough saliva make the examination difficult because the mucosa starts to stick to the mirror and to the fingers. Normal individuals will have pool of saliva on the floor of the mouth when they raise their tongue and the mucosa looks moist.

*Remember:
The main salivary glands are: parotid, submandibular and sublingual. Sometimes the submandibular gland in some patients is apparent extraorally and this can make confusion to the examiner because he may think that it's lymph node. Patients who have enlargement in the salivary gland we can see it exraorally except the sublingual enlargement we see it intraorally.

The End Best of luck