Oral Cavity Examination – OSCE Guide

Support us by buying our PDF booklet which contains over 100 OSCE checklists


Oral cavity examination occasionally appears in OSCEs and you’ll be expected to identify relevant signs using your clinical examination skills. This guide provides a step-by-step approach to performing an examination of the oral cavity in an OSCE setting.


Introduction

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Briefly explain what the examination will involve using patient-friendly language.

Gain consent to proceed with the examination.

Ask the patient to sit on a chair.

If the patient has any dentures or implants, ask them to remove them for the assessment.

Check if the patient currently has any pain before proceeding with the clinical examination.

Wash your hands.

Don some non-sterile gloves.


Gather equipment

  • Headtorch or pen torch
  • Tongue depressors (x2)

General inspection

Inspect the patient’s face for swelling:

  • Parotid gland swelling: causes loss of the angle of the jaw and a hamster-like appearance of the cheek on the affected side.
  • Submandibular gland swelling: apparent below and anterior to the angle of the mandible.
  • Anatomy of the oral cavity
    Anatomy of the oral cavity 1

Closer inspection

Ask the patient to open their mouth and inspect the oral cavity using your light source. Note if the patient has difficulty opening their mouth due to pain, suggesting the presence of trismus.

Lips

With the patient’s mouth open, use your light source to inspect the lips for abnormalities such as:

  • Angular stomatitis: a common inflammatory condition affecting the corners of the mouth. It has a wide range of causes, including iron deficiency (e.g. gastrointestinal malignancy, malabsorption).
  • Hyperpigmented macules: pathognomonic for Peutz-Jeghers syndrome,  an autosomal dominant genetic disorder that results in the development of polyps in the gastrointestinal tract.
  • Ulceration: may be secondary to trauma, infections (e.g. herpes simplex) or rarely malignancy.
  • Anglular stomatitis
    Anglular stomatitis 5

Teeth and gums

Using two tongue depressors inspect the teeth and gums.

Teeth

  • Missing teeth: may be secondary to infection or trauma.
  • Nicotine staining: present in patients who smoke (a significant risk factor for oral malignancy).
  • Tooth decay: indicative of poor oral hygiene.

Gums

  • Gingivitis: inflammation of the gums that has a variety of causes include excess plaque, vitamin C deficiency, HIV and leukaemia.
  • Periodontitis: can develop if gingivitis is left untreated and involves inflammation of the periodontal ligament. The condition can ultimately lead to the formation of peridontal abscesses and tooth loss.
  • Ulceration: may be secondary to trauma, infections (e.g. herpes simplex) or rarely malignancy.
  • Gingivitis
    Gingivitis 7

Tongue

Ask the patient to stick out their tongue and inspect for abnormalities such as:

  • Oral candidiasis: a fungal infection commonly associated with immunosuppression. It is characterised by pseudomembranous white slough which can be easily wiped away to reveal underlying erythematous mucosa.
  • Glossitis: smooth erythematous enlargement of the tongue associated with iron, B12 and folate deficiency (e.g. malabsorption secondary to inflammatory bowel disease).
  • Ulceration: may be secondary to trauma, infections (e.g. herpes simplex) or rarely malignancy.
  • Hairy leukoplakia: a white patch on the side of the tongue with a hairy appearance associated with Epstein-Barr virus infection in immunocompromised patients.
  • Oral candidiasis
    Oral candidiasis 8

Buccal mucosa and parotid duct

Using one tongue depressor move the tongue to either side and inspect the buccal mucosa and parotid duct.

Buccal mucosa

  • Aphthous ulcers: benign, non-contagious, erythematous, painful small, round oral ulcers with circumscribed margins. Their aetiology is unclear and likely multifactorial.
  • Other ulcers: if an ulcer has been present for more than 7-10 days, malignancy should be considered.

Parotid duct

  • Parotid gland sialolithiasis: a calcified stone blocking excretion of the parotid gland resulting in swelling and increased prominence of the duct.
  • Parotid gland sialoadenitis: infection of the parotid gland, typically secondary to sialolithiasis but other causes include viral infections (e.g. mumps). There may be erythema around the duct and visible discharge.
  • Pleomorphic adenoma: the most common type of tumour affecting the parotid gland. Typical presenting features include a solitary, slow-growing, painless, firm single nodular mass.
  • Parotid duct (Stenson's duct)
    Parotid duct (Stenson's duct) 11
Parotid gland

The parotid glands are the largest salivary glands and are located posterolaterally to the mandibular ramus (bilaterally). On each side of the face, the parotid duct pierces the buccinator muscle and opens into the oral cavity through the buccal mucosa, opposite the maxillary second molar.

Palate and uvula

Using one tongue depressor, gently depress the tongue and inspect the palate and uvula for abnormalities such as:

  • Oral candidiasis: a fungal infection commonly associated with immunosuppression. It is characterised by pseudomembranous white slough which can be easily wiped away to reveal underlying erythematous mucosa.
  • Ulceration: may be secondary to trauma, infections (e.g. herpes simplex) or rarely malignancy.
  • Papillomas: tumours derived from epithelium, that appear as cauliflower-like projections arising from the surface of the palate and uvula. They are associated with human papillomavirus (HPV) infection.
  • Aphthous ulcer
    Aphthous ulcer 12
Palate and uvula anatomy

The palate forms the roof of the mouth and separates the nasal cavity from the oral cavity. It can be further sub-divided into the:

  • Hard palate: the immobile portion of the palate comprised of bone.
  • Soft palate: the mobile portion of the palate comprised of muscle fibres covered by a mucous membrane. The soft palate elevates during swallowing to prevent a food bolus from entering the nasopharynx.

The uvula is a fleshy extension that projects from the back edge of the soft palate. In healthy individuals, it should be positioned in the midline of the palate.

Tonsils, pharyngeal arches and uvula

Using one tongue depressor, gently depress the tongue and inspect the tonsils, pharyngeal arches and uvula for abnormalities.

Tonsils

  • Enlargement: most often due to infection (tonsilitis), in which case there is also erythema and often exudate. Tonsillar enlargement may also be a chronic condition (e.g. tonsillar hypertrophy).
  • Asymmetry: tonsilitis can cause asymmetrical tonsillar swelling, however other causes of unilateral tonsillar swelling include tonsillar stones and malignancy.
  • Tonsillar ulceration: may be caused by viral infections (e.g. herpes simplex), however, malignancy should also be considered.
  • Tonsillar stones: caused by mineralisation of debris trapped within the tonsils. The stones may be visible on inspection of the tonsils and are usually asymptomatic.

Pharyngeal arches

  • Peritonsillar swelling: typically caused by a peritonsillar abscess (quinsy), in which pus is trapped between the tonsillar capsule and the lateral pharyngeal wall.
  • Pharyngitis: inflammation of the pharynx with several possible causes including viral infections, bacterial infections and chemical irritation (e.g. acid-reflux).

Uvula

  • Uvula deviation: may be caused by a peritonsillar abscess, with the uvula deviating away from the abscess. A glossopharyngeal nerve lesion can also cause uvula deviation away from the side of the lesion. If there are no other symptoms or signs, uvula deviation is likely a normal finding.
  • Oral cavity anatomy
    Oral cavity anatomy 14
Tonsilar anatomy

The palatine tonsils are located at the right and left sides of the back of the throat between the palatoglossal and palatopharyngeal arches of the soft palate. The palatoglossal arch is also known as the anterior tonsillar pillar and the palatopharyngeal arch is also known as the posterior tonsillar pillar. The tonsils appear as pinkish lumps and play an important role in immunity.

Floor of the mouth

Ask the patient to lift their tongue to the roof of their mouth and assess the floor of the mouth for pathology such as:

  • Submandibular gland sialolithiasis: a calcified stone blocking excretion of the submandibular gland resulting in swelling and increased prominence of the duct. There may be erythema around the duct and visible discharge.
  • Submandibular gland sialoadenitis: infection of the submandibular gland, typically secondary to sialolithiasis but other causes include viral infections (e.g. mumps). There may be erythema around the duct and visible discharge.
  • Ulceration: may be secondary to trauma, infections (e.g. herpes simplex) or rarely malignancy.
  • Salivary stone in submandibular salivary duct
    Salivary stone in submandibular salivary duct 19
Submandibular and sublingual glands

The paired submandibular glands are located on the floor of the mouth and are responsible for producing saliva. These glands are responsible for the majority of salivary duct calculi, possibly due to the torturous uphill course of the submandibular gland’s duct. The submandibular gland’s ducts open out on either side of the lingual frenulum as small prominences known as sublingual caruncles.

The paired sublingual glands are also located on the floor of the mouth, behind the mandibular canines, and are responsible for producing saliva. The glands are drained by 8-20 ducts known as the ducts of Rivinus. The largest sublingual duct joins the submandibular duct to drain through the same sublingual caruncle. The rest of the ducts open into the mouth on an elevated region of mucous membrane known as the plica sublingualis.


Palpation

If permitted by the patient and examiner, proceed to bimanual palpation of the mouth.

Bimanual palpation of the mouth

1. With one finger palpating the neck externally and the other gloved finger in the oral cavity, gently palpate any identified lumps from both sides.

2. Palpate the lateral walls of the mouth to assess the parotid gland and duct.

3. Palpate the floor of the mouth to assess the submandibular gland and sublingual gland.

Any intraoral swelling should be described according to its site, size, thickness, colour, texture, consistency and tenderness.


To complete the examination…

Explain to the patient that the examination is now finished.

Thank the patient for their time.

Wash your hands.

Summarise your findings.

Example summary

“Today I performed an examination of the oral cavity on Mr Smith, a 30-year-old male who presented with a submandibular swelling.”

“On inspection, dentition was normal and a small, erythematous swelling was noted on the floor of the mouth, beside the lingual frenulum. On bimanual palpation, the lump was hard and non-tender. These findings are consistent with a salivary duct stone.”

“For completeness, I would like to perform the following further assessments and investigations.”

Further assessments and investigations

  • Examination of the neck, ears and temporomandibular joint.
  • Flexible nasal endoscopy: to visualise the back of the oral cavity in greater detail.
  • Orthopantomogram: if there are concerns about tooth cavities.
  • Ultrasound neck +/- fine-needle aspiration: to further assess any neck or salivary gland lumps.
  • CT and MRI: if oropharyngeal cancer suspected.

References

  1. Blausen.com staff (2014). WikiJournal of Medicine. Adapted by Geeky Medics. Anatomy of the oral cavity. Licence: CC BY 3.0. Available from: [LINK].
  2. James Heilman, MD. Adapted by Geeky Medics. Submandibular gland. Licence: CC BY-SA. Available from: [LINK].
  3. n.raveender. Adapted by Geeky Medics. Parotid tumour. Available from: [LINK].
  4. Yeanold Viskersenn. Adapted by Geeky Medics. Mumps. Licence: CC BY-SA. Available from: [LINK].
  5. Adapted by Geeky Medics. Matthew Ferguson. Angular stomatitis. Licence: CC BY-SAAvailable from [LINK].
  6. Adapted by Geeky Medics. Abdullah Sarhan. Peutz-Jager syndrome. Licence: CC BY-SAAvailable from [LINK].
  7. Onetimeuseaccount. Adapted by Geeky Medics. Gingivitis. Licence: CC BY-SA. Available from: [LINK].
  8. Adapted by Geeky Medics. James Heilman, MD. Oral candidiasis. Licence: CC BY-SAAvailable from [LINK].
  9. Adapted by Geeky Medics. Klaus D. Peter, Gummersbach. Glossitis. Licence: Klaus D. Peter, Gummersbach, Germany. Licence: CC BY 3.0 DEAvailable from [LINK].
  10. Aitor. Adapted by Geeky Medics. Leukoplakia. Available from: [LINK].
  11. DRosenbach. Adapted by Geeky Medics. Stenson’s duct. Licence: CC BY-SA. Available from: [LINK].
  12. Ryanfransen. Adapted by Geeky Medics. Aphthous ulcer. Available from: [LINK].
  13. GalliasM. Adapted by Geeky Medics. HPV warts in the throat. Licence: CC BY-SA. Available from: [LINK].
  14. Klem. Adapted by Geeky Medics. Oral cavity anatomy. Licence: CC BY. Available from: [LINK].
  15. Dake. Adapted by Geeky Medics. Pharyngitis. Licence: CC BY-SA. Available from: [LINK].
  16. Michaelbladon. Adapted by Geeky Medics. Tonsillitis. Available from: [LINK].
  17. James Heilman, MD. Adapted by Geeky Medics. Peritonsillar abscess. Licence: CC BY-SAAvailable from: [LINK].
  18. Phreezinc. Adapted by Geeky Medics. Tonsil stone. Available from: [LINK].
  19. James Heilman, MD. Adapted by Geeky Medics. Salivary stone. Licence: CC BY-SAAvailable from: [LINK].

Print Friendly, PDF & Email