(MOUTH) ASSESSMENT OF THE MOUTH & PHARYNX INSPECTION

Lips

Observe consistency & color

Lips sample documention

Pinkish, smooth & moist s lesions or swelling

Circumoral Pallor

Lips Abnormal Findings:

pale area around the mouth

(anemia)

Circumoral Pallor

Lips Abnormal Findings

Bluish (Cyanotic) Lips

Lips Abnormal Findings:
oxygenation problems; cardiac arrest

Bluish (Cyanotic) Lips

Lips Abnormal Findings

Reddish Lips

Lips Abnormal Findings:

liver problems; carbon monoxide problems

Reddish Lips

Lips Abnormal Findings

Cheilosis

Lips Abnormal Findings:

an inflammatory condition that causes cracking, crusting , and scaling of the corners of the mouth

Cheilosis

Lips Abnormal Findings

Herpes simplex

Lips Abnormal Findings:

crust (STI)

Herpes simplex

Lips Abnormal Findings

Cleft Lip

Lips Abnormal Findings:

an opening or split in the upper lip that doesn't close fully when an unborn baby is developing in the womb

Cleft Lip

Lips Abnormal Findings

Teeth & gums what to asses

Note number, color, condition & alignment of teeth; examine gums for color & consistency

Teeth and gums sample documention

32 white to yellowish teeth present; no repaired or decayed areas; no dental appliance; gums pink, moist & firm c tight margins to the tooth; no lesions, redness or swelling noted

Dental Caries

Teeth & gums Abnormal Findings:

tooth decay

Dental Caries

Teeth & gums Abnormal Findings

Malocclusion

Teeth & gums Abnormal Findings:

the teeth are not aligned properly

Malocclusion

Teeth & gums Abnormal Findings

Gingivitis

Teeth & gums Abnormal Findings:

earliest stage of gum disease; inflammation

Gingivitis

Teeth & gums Abnormal Findings

Receding gums

Teeth & gums Abnormal Findings:

gums atrophy

Receding gums

Teeth & gums Abnormal Findings

Gingival Hyperplasia

Teeth & gums Abnormal Findings:

an overgrowth of gum tissue around the teeth .

Gingival Hyperplasia

Teeth & gums Abnormal Findings

Buccal Mucosa what to assess

Note color & consistency; examine Stenson’s ducts/parotid gland
2nd and 3rd upper mucosa

Buccal Mucosa sample documentation

Pinkish, smooth & moist s lesions; Stenson’s ducts visible s redness, swelling or pain

Aphthous Ulcer

Buccal Mucosa Abnormal Findings:

canker sore, “luas”

Aphthous Ulcer

Buccal Mucosa Abnormal Findings

Koplik Spots

Buccal Mucosa Abnormal Findings:

peculiar spots present on the buccal mucosa, whitish spots and be scrapped off; measles.

Koplik Spots

Buccal Mucosa Abnormal Findings

Tongue what to assess

Note color, moisture, size, texture, fasciculation, midline protrusion, lesions & induration; examine ventral surface, frenulum, area under tongue, Wharton’s ducts & sides of tongue

Tongue sample documentation

Moist, pinkish, at midline, s lesions, nodules or fasciculations; papillae present on dorsal surface; ventral surface smooth & shiny pink c small visible veins present; frenulum in midline c visible Wharton;s ducts on each side

Fissured duct

Tongue Abnormal Findings:

dehydration

Fissured duct

Tongue Abnormal Findings

Black, hairy tongue

Tongue Abnormal Findings:

s/e of antibiotics, fungi growth

Black, hairy tongue

Tongue Abnormal Findings

Smooth, reddish, shiny tongue w/o papillae

Tongue Abnormal Findings:

(“beefy red tongue”) - pernicious anemia

Smooth, reddish, shiny tongue w/o papillae

Tongue Abnormal Findings

Leukoplakia

Tongue Abnormal Findings:

precancerous lesion, whitish patch and painless

Leukoplakia

Tongue Abnormal Findings

Carcinoma of the tongue

Tongue Abnormal Findings:

form of ulcer and tongue CA

Carcinoma of the tongue

Tongue Abnormal Findings

Candida Albicans Infection (Oral Thrush)

Tongue Abnormal Findings:

condition in which the fungus candida albicans accumulates on the lining of your mouth; scraped off leads to bleeding

Candida Albicans Infection (Oral Thrush)

Tongue Abnormal Findings

Palate what to assess

Note color & integrity of soft & hard palate

Palate sample documentation

Whitish hard palate c firm transverse rugae; smooth, pink & moist soft palate; no lesions noted

Torus Palatinus

Palate Abnormal Findings:

is a harmless, painless bony growth located on the roof of the mouth (hard palate); Native Americans

Torus Palatinus

Palate Abnormal Findings

Cleft Palate

Palate Abnormal Findings:

an opening or split in the roof of the mouth that occurs when the tissue doesn't close fully during development in the womb before birth

Cleft Palate

Palate Abnormal Findings

Breath Odor sample documentation

No unusual or foul odor noted

ODOR: Fruity or Acetone Breath

IMPLICATION: Diabetic ketoacidosis

ODOR: Ammonia odor

IMPLICATION: Kidney Disease

ODOR: Foul odor

IMPLICATION: Oral or respiratory infection or tooth decay

ODOR: Sulfur odor (“fetor hepaticus”)

IMPLICATION: End-stage liver disease

Uvula what to asses

Note characteristics & positioning

Pinkish; midline

Uvula sample documentation

Pinkish, moist, has freely in midline s̅ redness or exudate

Tonsils what to assess

note color, size & presence of swelling,exudate or lesions

Tonsils sample documentation

1+, pink, symmetric s̅ exudate, swelling or lesions

Tonsillitis

Tonsils abnormal findings:

inflammation of tonsil (palantine) with yellowish exudate

Tonsillitis

Tonsils abnormal findings:

Oropharynx or posterior pharyngeal wall what to assess

Note color & presence of exudate or lesions

Oropharynx or posterior pharyngeal wall sample documentation

Pink s̅ exudate or lesions

Gag reflex

Intact