A n a t o m i c a n d Ex a m i n a t i o n

Considerations of the Oral

Cavity
Mansoor Madani, DMD, MDa,b,c, Thomas Berardi, DMD
d
,
Eric T. Stoopler, DMD, FDS RCSEd, FDS RCSEngd,*

KEYWORDS
 Oral anatomy  Oral examination  Oral mucosa  Dentition

KEY POINTS
 Patients often present to their physician for evaluation of dental and/or oral complaints.
 Physicians must have an understanding of basic oral anatomy and how to perform a
clinical examination of the oral cavity.
 From the physical examination findings, physicians should be able to determine whether
the oral cavity is in a state of health or disease.

INTRODUCTION

Comprehensive examination of the oral cavity is an area of physical diagnosis that

traditionally receives decreased emphasis in the predoctoral medical curriculum
and in clinical medical practice. Important information can be gained through a sys-
tematic evaluation of the oral hard and soft tissues. Although the primary objective
is to distinguish between health and disease, a comprehensive oral examination, in
conjunction with a thorough medical and dental history, can also provide valuable
insight into the overall health and well-being of the patient. Minor changes in oral struc-
ture and function may adversely affect an individual’s quality of life. In this article,
anatomic considerations and clinical examination techniques of the oral cavity are
discussed.

Disclosures: Dr. Stoopler receives an honorarium from WebMD for providing expert viewpoints
and royalties from the American Dental Association.
a
Department of Oral and Maxillofacial Surgery, Capital Health System, 750 Brunswick Avenue,
Trenton, NJ 08638, USA; b Oral & Maxillofacial Surgery, Temple University, 3401 North Broad
Street, Philadelphia, PA 19140, USA; c Center for Corrective Jaw Surgery, 15 North Presidential
Boulevard, Bala Cynwyd, PA 19004, USA; d Department of Oral Medicine, University of Pennsyl-
vania School of Dental Medicine, 240 South 40th Street, Philadelphia, PA 19104, USA
* Corresponding author.
E-mail address: [email protected]

Med Clin N Am - (2014) -–-

http://dx.doi.org/10.1016/j.mcna.2014.08.001 medical.theclinics.com
0025-7125/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
2 Madani et al

ANATOMIC CONSIDERATIONS

Examination of the oral cavity, in addition to the head and neck, are essential compo-
nents of a patient’s comprehensive physical examination. The boundary of the oral
cavity is made of the lips anteriorly, the cheeks laterally, the floor of the mouth inferi-
orly, the oropharynx posteriorly, and the palate superiorly. The oropharynx is the area
starting superiorly between the hard and the soft palate, and ends inferiorly behind the
circumvallate papillae of the tongue. The hard tissue bases that these structures are
attached to are the mandible and maxillae.1,2

Dentition and Supporting Structures

Typically, there are 32 teeth present in the oral cavity of an adult, with the first perma-
nent tooth generally appearing by age 6 years. There are 20 primary teeth in childhood.
Teeth are classified as central and lateral incisors, canines, premolars, and molars.
There are no premolars or third molars in the primary dentition. Third molars appear
in the mid to late teenage years, but many times do not have adequate space to erupt,
often resulting in impaction, and may cause pain and/or infection. Permanent teeth
may be classified according to different systems, but the most common method
used in the United States is the Universal numbering system.3,4 In this system, teeth
are counted starting from the right maxilla (#1 for the right maxillary third molar) to
the left maxilla (#16 for the left maxillary third molar), continuing to the left mandible
(#17 for the left mandibular third molar) and ending in the right mandible (#32 for the
right mandibular third molar) (Fig. 1). The primary teeth are labeled using the alphabet,

Fig. 1. Universal numbering system for permanent teeth as recommended by the Federation
Dentaire Internationale (FDI). (From Yasny JS, Herlich A. Perioperative dental evaluation. Mt
Sinai J Med 2012;79:34–45; with permission. http://dx.doi.org/10.1002/msj.21292. Available
at: http://onlinelibrary.wiley.com/doi/10.1002/msj.21292/full#fig1.)
 Oral Cavity 3

starting with the letter A for the second primary molar in the right maxilla and ending
with the letter T for the second primary molar in the right mandible.4
Each tooth is divided into 2 parts, the crown and the root(s). The outer portion of the
crown is covered by enamel, the hardest substance in the body. Dentin, which is
immediately below the enamel layer, forms the bulk of the tooth and can be sensitive
if the protective enamel is lost. The soft tissue containing the blood and nerve supply
to the tooth (pulp) is housed within the dentin, extending from the tip of the root to the
crown. A layer of cementum covers the root, which aids in attaching the tooth to the
bony socket (Fig. 2).
Supporting structures of the teeth (periodontium) include the periodontal ligament,
gingival tissue, bone, blood, and nerves. The periodontal ligament is made up of thou-
sands of fibers, which fasten the cementum to the bony socket and alveolar bone, and
act as shock absorbers for the teeth, which are subjected to heavy forces during func-
tion. These ligaments also function as sensory, nutritive, and remodeling structures
surrounding the roots. Gingival tissue covers teeth and bone to protect them and
provides an easily lubricated surface. The alveolar portions of the maxillary and
mandibular bones contain sockets to support the roots of the teeth. Each tooth and
periodontal ligament has a nerve supply, and the teeth are sensitive to a wide variety
of stimuli. The blood supply is necessary to maintain the vitality of the tooth. The maxil-
lary and mandibular divisions of the trigeminal nerve innervate the teeth and the
periodontium.

Fig. 2. Anatomy of a tooth. (From Yasny JS, Herlich A. Perioperative dental evaluation.
Mt Sinai J Med 2012;79:34–45; with permission. http://dx.doi.org/10.1002/msj.21292. Avail-
able at: http://onlinelibrary.wiley.com/doi/10.1002/msj.21292/full#fig2.)
4 Madani et al

Lips and Oral Mucosa

The lips are musculofibrous structures that are critical to eating, swallowing, speaking,
whistling, singing, expectoration, and common human behavioral communications,
such as kissing, smiling, and pouting. The lips are composed of 4 tissue layers: cuta-
neous, muscular, glandular, and mucosa. The juncture where the lips meet the sur-
rounding skin of the mouth is the vermillion border. The areas of the upper and
lower lip meet at the corner of the mouth and are called labial commissures. The
commissure is important in facial appearance, particularly during functions such as
smiling. The maxillary and mandibular branches of the trigeminal nerve (V2 and V3,
respectively) innervate the upper and lower lips. The infraorbital branches of V2 inner-
vate the upper lip and the surrounding skin of the face between the upper lip and the
lower eyelid, except for the bridge of the nose. The mental nerve branch of V3 inner-
vates the lower lip, mucosa, and the labial gingival tissues anteriorly. The facial artery
supplies the blood to the lips.5–8

Tongue and Floor of the Mouth

The tongue occupies the major part of the oral cavity and oropharynx. The tongue has
several important functions, including swallowing, mastication, speech, and taste.
Tongue movements also help clear food debris from the oral cavity. The major salivary
glands, parotid, submandibular (or submaxillary), and sublingual glands, produce
saliva to assist with swallowing. Five cranial nerves contribute to the complex innerva-
tion of this multifunctional organ. Motor innervation for all of the muscles of the tongue
comes from the hypoglossal nerve (cranial nerve [CN] XII), with the exception of the
palatoglossus, which is supplied by the pharyngeal plexus (fibers from the cranial
root of the spinal accessory nerve carried by the vagus nerve [CN X]).
General sensation of the anterior two-thirds of the tongue is supplied by the lingual
nerve, a terminal branch of V3. Taste sensation for this portion of the tongue is carried
by the chorda tympani branch of the facial nerve (CN VII). The posterior one-third of the
tongue relays general sensation via the lingual-tonsillar branch of the glossopharyng-
eal nerve (CN IX). Some general and taste sensation from the base of tongue anterior
to the epiglottis is carried by the internal laryngeal branch of the superior laryngeal
nerve (CN X).
The surface of the tongue is covered by various projections of lamina propria
covered with epithelium known as lingual papillae. There are 4 types of papillae:
circumvallate (vallate), foliate, filiform, and fungiform. The circumvallate papillae are
raised, dome-shaped structures that typically present in a V-shaped pattern in the
posterior one third of the tongue. The foliate papillae are small folds of mucosa located
along the lateral surface of the tongue. The filiform papillae are thin and long; they are
the most numerous papillae and are located along the entire dorsum of the tongue,
but are not involved in taste sensation. The fungiform papillae are mushroom-
shaped and are dispersed most densely along the tip and lateral surfaces of the
tongue.
The floor of the mouth forms the inferior limit of the oral cavity. In its most anterior
section, the lingual frenum connects the tongue muscles to the gingival tissues. Sub-
lingual papillae (caruncles) are present on either side of the lingual frenum. The excre-
tory duct of the submandibular gland (Wharton’s duct) is situated in the floor of the
mouth along the medial border of the sublingual gland to pierce the surface of the
mouth at these sublingual caruncles. In the more posterior floor of the mouth, just
below the tongue, are the sublingual folds, which house the sublingual glands, with
multiple small ducts to drain saliva in the mouth.
 Oral Cavity 5

Palate and Upper Oropharynx

The palate is the U- or V-shaped arched roof of the oral cavity. The anterior section is
the hard palate with oral mucosa firmly attached. The hard palate separates the oral
cavity from the nasal cavities. The incisive bone, or premaxilla, and the palatine pro-
cesses of the maxilla form the anterior two-thirds of the hard palate. The horizontal
plates of the palatine bone form the posterior one-third of the hard palate. The midline
elevated suture line of the hard palate is termed the median or palatine raphe. The
transverse ridges (or rugae) make up the anterior palate.
The soft palate forms the posterior aspect of the palate; in the presence of the uvula
and the movable section of the roof of the mouth, it constitutes the oropharynx and
separates it from the nasopharynx. This part of the palate controls the act of swallow-
ing and prevents food regurgitation into the nasal cavity. On the sides of the uvula,
there are extensions of the soft palate in 2 directions. The anterior section connecting
the soft palate to the tongue is termed the palatoglossal arch, and the posterior sec-
tion connects the palate to the pharynx and is known as palatopharyngeal arch. These
arches are also known as anterior and posterior palatal pillars. The palatine tonsils are
generally located between these 2 arches.
During a comprehensive oral examination, it is important to evaluate the dentition,
oral mucosa, gingival tissues, tongue, floor of the mouth, hard and soft palate, uvula,
and tonsils for any changes in color, texture, and presence of lesions. This examina-
tion typically is of short duration, but the importance of clinical evaluation of the oral
cavity in relation to systemic diseases should not be underestimated.

CLINICAL EXAMINATION CONSIDERATIONS

To perform the examination, it is best to have the patient seated in an upright position.
The examiner can use one hand to support the back of the head, but the preferred po-
sition is to examine the patient in a chair with head support. Patients who are in a
wheelchair can easily be examined without moving them out of the chair. Adequate
lighting is essential for a proper examination of the oral cavity. For bedridden patients,
the examination can take place at bedside using a tongue blade and flashlight. Placing
a pillow under the patient’s head will allow the examiner to have easy access to the
oral cavity. In any situation, the examiner needs a flashlight or clinical examination
light, tongue depressors, examination gloves, and 2  2 gauze sponges to dry the
mucosa and/or hold the tissue structures for careful examination. It is important to
develop a systematic procedure for performance of a clinical examination.

Extraoral Examination
Physicians have expertise in performing a head and neck examination, including eval-
uation of the cranial nerves, lymph nodes, thyroid gland, and general skeletal and
facial features. This section reviews pertinent aspects of the extraoral examination
with relevance to the oral cavity.

Head, face, and chin

Face the patient from front and evaluate for facial symmetry, presence of any masses,
swelling, bruising, discolorations, or signs of trauma. Obvious asymmetry may be an
indicator of congenital deformity, malocclusion, infection, neoplastic growths, muscle
atrophy or hypertrophy, and neurologic problems. Asymmetry may also be associ-
ated with temporomandibular joint (TMJ) dysfunction. A detailed discussion of the
TMJ can be found in the article by De Rossi, et al. elsewhere in this issue on tempo-
romandibular disorders.
6 Madani et al

Salivary glands
The major salivary glands are best examined by palpation and observation of salivary
flow. The parotid gland lies on the lateral surface of the mandibular ramus and folds
itself around the posterior border of the mandible (Fig. 3). It is generally soft and is
not usually palpable as a discrete gland. The anterior border of the gland may be better
defined by having the patient clench the teeth together, which tenses the masseter
muscle. The parotid gland lies just behind the masseter, and its consistency may be
appreciated by pressing the gland on its lateral surface against the mandibular
ramus.9–13 Parotid secretions are carried to the oral cavity by Stensen’s duct, which
enters the oral cavity in the cheek just opposite the maxillary second molar tooth. It
is visible as a small papilla in the buccal mucosa (Fig. 4). Careful observation of this
papilla during palpation of the gland will usually reveal saliva coming from the small
duct orifice. Sometimes it is helpful to dry the mucosa in the vicinity of the duct with
dry gauze to visualize the flow more easily. The saliva from the parotid gland is usually
clear, thin, and colorless. The clinician should look carefully for suppuration, mucus, or
particulate matter in the secretion.
The submandibular gland lies just below the inferior border of the mandibular body,
and is best palpated bimanually with one hand in the lateral floor of the mouth and the
other on the submandibular gland (Fig. 5). The gland is usually soft and mobile, and
should not be tender to palpation. The submandibular duct (Wharton’s duct) runs su-
periorly and anteriorly to empty adjacent to the frenulum of the tongue. The small duct
orifice is visible in the top of a papilla in this area (Fig. 6). Observation of salivary flow
during palpation is important. The submandibular gland is more commonly associated
with stone formation than the other salivary glands because (1) the secretion is more
mucoid, and (2) the gland lies in a dependent position relative to the duct orifice; this
may lead to stasis of secretions in the proximal duct. The sublingual glands lie just
beneath the mucosa in the floor of the mouth and empty directly into the mouth or
into the submandibular duct. The gland is not discretely palpable, nor are the duct
openings usually visible. Salivary glands that are painful, swollen, and indurated
may indicate abnormality associated with these structures. Palpation of the sublingual
salivary gland, careful assessment of each duct, and the total salivary flow should be
noted during the intraoral examination.

Fig. 3. Examination of the parotid gland. (Courtesy of Mansoor Madani, DMD, MD, Bala
Cynwyd, PA; all rights reserved.)
 Oral Cavity 7

Fig. 4. Location of Stenson’s duct papilla. (Courtesy of Mansoor Madani, DMD, MD, Bala
Cynwyd, PA; all rights reserved.)

Fig. 5. Examination of the submandibular gland. (Courtesy of Mansoor Madani, DMD, MD,
Bala Cynwyd, PA; all rights reserved.)

Fig. 6. Sublingual caruncle. (Courtesy of Mansoor Madani, DMD, MD, Bala Cynwyd, PA; all
rights reserved.)
8 Madani et al

Intraoral Examination
As with any clinical examination, this portion should be completed in a systematic
manner.14–16 Tissues should be visually examined and palpated to appreciate normal
and pathologic findings (if present).

Lips
Examination of the lips are an essential part of the physical evaluation. Generally, lips
should be homogeneously pink in color, smooth and symmetric. The vermillion border
should be clearly defined. When examining the lips, gently hold the lip between thumb
and forefinger and roll it downward. Note the difference in the appearance of the
normal tissue between the dry border and the wet mucous membrane. Palpate the
lip for irregularities, such as submucosal nodules or areas of tenderness (Fig. 7).
Inspect the color of the labial mucosa, and note the presence of ulcers, blisters,
growths, or thickness changes. In addition, it is recommended to examine the pa-
tient’s perioral areas for any signs of abnormality. There are normal variations of
various conditions in the lips, such as presence of ectopic sebaceous glands and
pigmentation changes related to patients’ skin color, which should not be mistaken
for pathologic conditions (see the article by Madani and Kuperstein elsewhere in
this issue on normal variations of oral anatomy and common oral soft tissue lesions).

Labial and buccal mucosa

The labial and buccal mucosae line the inner part of the oral cavity covering the cheek
and the lips. The mucosa is nonkeratinized in these regions. Clinical examination is
performed by direct visualization as well as bimanual palpation of these tissues
(Figs. 8–10). The mucosa should have a uniform consistency and appear pink in color.
The parotid papilla, as previously described, should be visible bilaterally and may be
confused with a pathologic condition. Any variations in color or texture, or the pres-
ence of lines or masses must be carefully evaluated and referred to a dental profes-
sional for further evaluation and management.

Tongue and floor of the mouth

The best position for examining this area is with the patient’s oral cavity at eye level
and the practitioner in front of or at the side of the patient. Grasp the tip of the tongue
with a 2  2 gauze, move the tongue slightly out, and examine areas above, below,

Fig. 7. Palpation of the lip. (Courtesy of Mansoor Madani, DMD, MD, Bala Cynwyd, PA; all
rights reserved.)
 Oral Cavity 9

Fig. 8. Examination of the labial mucosa. (Courtesy of Mansoor Madani, DMD, MD, Bala
Cynwyd, PA; all rights reserved.)

Fig. 9. Inspection of the buccal mucosa. (Courtesy of Mansoor Madani, DMD, MD, Bala
Cynwyd, PA; all rights reserved.)

Fig. 10. Palpation of the buccal mucosa. (Courtesy of Mansoor Madani, DMD, MD, Bala
Cynwyd, PA; all rights reserved.)
10 Madani et al

and on the sides of the tongue (Fig. 11). Inspect the color and texture of dorsal, ventral,
and lateral surfaces. Observe for plaques, ulcerations, thickenings, and/or changes in
papillae, and palpate the patient’s tongue to evaluate for areas of induration and/or
pain.
The floor of the mouth is also examined by direct visualization as well as bimanual
palpation (Fig. 12). In general, ask the patient to lift their tongue and move it from side
to side and note any deviation or limitation of motion. The sublingual space typically
does not have highly keratinized epithelium.
The middle fold of the ventral surface of the tongue is termed the lingual frenum.
Ordinarily, this frenum attaches about one-third of the way back from the tip of the
tongue. At the base of the lingual frenum are the salivary ducts, which include the
openings to the submandibular ducts (Wharton’s duct), sublingual caruncle, and sub-
lingual folds, as previously described (Fig. 13).
Near the posterior limits of the sublingual space and near the lingual border of the
mandible, salivary eminences mark the superior surfaces of the sublingual glands.
The remaining portion of the gland lies in the lingual fossa, which is a shallow depres-
sion in the mandible itself.
Observe the opening of Wharton’s duct in the floor of the mouth and look for normal
drainage of saliva from this orifice. Particular attention should be paid to the junction of
the lateral border of the tongue, where the tongue base joins the anterior tonsillar pil-
lars, as it could be easily missed on examination.

Palate and uvula

The hard palate is generally covered by very thick, keratinized, pink mucosa. Exam-
ination is by direct visualization, palpation and observing for color variation, presence
of masses, swellings and ulceration (Fig. 14). There are several normal structures that
must be noted in the hard palate. Just behind the maxillary central incisors lies the
incisive papilla, a soft-tissue protuberance that covers the incisive foramen and nor-
mally appears more red in color compared to the surrounding tissues. There is a
slightly elevated line extending from the incisive papilla to the soft palate, known
as the midline raphe. On the sides of the raphe there are multiple corrugated ridges
radiating to the sides, called palatal rugae. The exact function and reason for their
presence is unknown, but it is believed that rugae help with speech and pronuncia-
tion. The tori, structures representing excessive bone growth, may be present in

Fig. 11. Examination of the tongue. (Courtesy of Mansoor Madani, DMD, MD, Bala Cynwyd,
PA; all rights reserved.)
 Oral Cavity 11

Fig. 12. Examination of the floor of mouth. (Courtesy of Mansoor Madani, DMD, MD, Bala
Cynwyd, PA; all rights reserved.)

the center of the palate. In general, palatal tori do not require removal unless the pa-
tient requires a denture and the presence of a torus interferes with denture fabrication
or insertion. Any suspected abnormality should be referred to the appropriate health
care provider for further evaluation and management.
The soft palate is examined using direct vision, and is normally not palpated unless
necessary. Inspect for consistency of color and the presence of ulcerations, thicken-
ings, exudates, or petechiae. Normally, this area is slightly less vascular than the
oropharynx, and is usually reddish-pink in color. Observe the area as the patient
says “ah.” The tissue should appear loose, mobile, and symmetric during function.
The tissue has a homogeneous, spongy consistency on palpation. Atypical observa-
tions include yellowish coloring from increased adipose tissue (especially in older pa-
tients), excessively long or short uvulas, and uvulas that appear slightly asymmetric at
rest. Occasionally one will discover a bifid (cleft) uvula.

Tonsils
The tonsils are located on either side of the pharynx and examined by direct visuali-
zation. Tonsils often have smooth surfaces with a light pink mucosal covering, but in

Fig. 13. Palpation of structures in the floor of mouth. (Courtesy of Mansoor Madani, DMD,
MD, Bala Cynwyd, PA; all rights reserved.)
12 Madani et al

Fig. 14. Examination of the palate. (Courtesy of Mansoor Madani, DMD, MD, Bala Cynwyd,
PA; all rights reserved.)

many instances, have rough, lobular shapes. On occasion, tonsillar crypts (cratered
surfaces within the tonsil) may be observed on clinical examination. These areas
are prone to collecting food debris, bacteria and calcified materials and may be a
source of chronic halitosis. The anterior and posterior pillars should appear vascular,
smooth, and symmetric. Examine the oropharynx by placing a mirror or tongue
depressor on the dorsal surface of the tongue, applying gentle pressure without hav-
ing the patient stick out the tongue. Visualize the posterior pharyngeal wall, anterior
and posterior pillars, and the tonsillar crypt and tonsils, if present. These areas are
normally not palpated unless there is a specific indication. The posterior pharyngeal
wall is typically reddish-pink in color, smooth and may contain surface prominences
(coral pink to transulcent in color) that are representative of lymphoid aggregates.17
Erythema and purulent exudate associated with pharyngitis (infection of the pharynx)
may cover portions of the pharyngeal wall. Observe for ulcers, erosions, or noticeable
enlargements or growths in the tonsillar region.

Fig. 15. Inspection of the dentition (in occlusion). (Courtesy of Mansoor Madani, DMD, MD,
Bala Cynwyd, PA; all rights reserved.)
 Oral Cavity 13

Fig. 16. Inspection of the dentition (open position). (Courtesy of Mansoor Madani, DMD,
MD, Bala Cynwyd, PA; all rights reserved.)

Dentition and occlusion

Inspect the entire dentition for number and position of teeth, tooth color, and intact
surfaces (Figs. 15 and 16). Tooth percussion is a valuable examination technique to
detect a possible dental abnormality in the absence of radiographs. The patient can
often identify which tooth is the source of dental pain.18 Multiple decayed or infected
teeth, poor oral hygiene, and/or inflamed gingival tissues may be observed, in which
case the patient should be referred to a dentist for further evaluation and
management.
In patients with normal dental occlusion (bite relationship), the maxillary anterior
teeth are positioned in front of the mandibular anterior teeth and the front cusp of
the maxillary first molar sits in the groove of the mandibular first molar. This type of
occlusion is known as class I occlusion.19 When a patient’s jaws are malaligned, it
is usually attributed to either mandibular retrognathism (lower jaw further posterior
to upper jaw than usual; class II malocclusion) or mandibular prognathism (lower
jaw anterior to upper jaw; class III malocclusion). In any of these situations, patients
may be unable to speak properly or chew food effectively. In addition, patients with
receded chin have more potential to develop sleep apnea.

Gingival and alveolar mucosa

Inspect the color and texture of the gingival and alveolar mucosa. The color of the
gingival mucosa is generally pink/coral, whereas alveolar mucosa appears red
because of increased vascularity. The texture of the gingiva is often smooth (although
minor stippling is often present) with tight, well-defined margins, and the alveolar
mucosa is consistent with other mucosal surfaces of the body. Observe for swelling,
ulceration, erythema, discoloration, atrophy, recession, bleeding, and/or enlargement.
Palpate any areas of enlargement to determine whether it is due to edema or an
underlying bony or fibrous process.

SUMMARY

Many patients with dental and oral diseases present to their physician for initial eval-
uation. Local and systemic diseases often manifest in the oral cavity, and physicians
should have an understanding of oral anatomy and the expertise to conduct a basic
clinical examination of this area to provide appropriate care to patients.
14 Madani et al

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