Intraoral Examination in Dentistry
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Direct answer
The intraoral examination is a fixed lap around the mouth — lips, labial and buccal mucosa, vestibules, alveolar ridges and gingiva, hard and soft palate, tongue on all surfaces, floor of the mouth, and finally the oropharynx — performed with good light, a mouth mirror and gloved fingers, before any focused examination of the complaint. Inspection is followed by palpation: bidigital palpation for the lips and cheek, bimanual palpation for the floor of the mouth and tongue, and direct palpation for the palate. In the Indian clinic the survey carries extra weight because the buccal mucosa, lateral tongue and retromolar region are the territory of tobacco-related cancer and potentially malignant disorders.
What you must remember
- Never examine only the complaint; run the full subsite survey first, then return to the lesion in detail.
- High-risk sites for oral cancer: buccal mucosa and retromolar trigone (the commonest sites in Indian patients), lateral and ventral tongue, floor of the mouth, soft palate and tonsillar complex.
- Describe an ulcer by site, size, shape, margins (punched out, undermined, rolled, everted), floor (slough, granulation) and base (induration) — everted margins and an indurated base point to carcinoma.
- Bimanual palpation is mandatory for the sublingual region and the body of the tongue; a sublingual swelling palpated with one hand only is half examined.
- The lateral border of the tongue is examined by protruding the tongue and grasping it with gauze to rotate it towards the opposite side.
- Record oral hygiene with the Oral Hygiene Index-Simplified (Greene and Vermillion): debris index plus calculus index, each scored 0–3 on six selected surfaces, total 0–6.
- Saliva should be assessed for flow and consistency — frothy, ropy saliva or a mirror sticking to the buccal mucosa signals hyposalivation.
- Check the circumvallate papillae before calling a midline dorsal coating abnormal; the lingual tonsil and papillae are normal anatomy, not pathology.
Approach to examining an oral ulcer
Take a 50-year-old man with a whitish patch and ulceration on the right buccal mucosa. Inspect first under good light after drying the mucosa: site (right buccal mucosa, mid-level), size measured with a scale (2.5 × 1.5 cm), irregular shape, surface part-white part-ulcerated, everted margins, floor covered with yellow slough. A rolled or everted margin means epithelium proliferating outwards over a destructive process — carcinoma until proven otherwise.
Next comes palpation, which contributes more than inspection: a stony hard base extending beyond the visible edge is the single most important clinical sign of malignancy, because the tumour infiltrates further than it appears — so the biopsy must include the margin and adjacent apparently normal mucosa, not the sloughed centre.
Then complete the survey: the opposite buccal mucosa (field cancerisation makes second primaries common), the commissures, all tongue surfaces, the floor of the mouth bimanually, the palate, and the oropharynx with a tongue depressor while eliciting the gag reflex. Feel the cervical nodes last, because they stage the disease, and document everything with measurements — site, size, extent, induration, nodes — and the plan for incisional biopsy.
High-yield viva angles
The viva loves methods of palpation: bidigital (two fingers, lips and cheek), bimanual (two hands, floor of mouth, tongue, submandibular gland — the "best" method for sublingual lesions), and bi-manual comparison of the parotid through the cheek and in the retromandibular depression. A favourite one-liner: "Which oral site is most commonly involved in Indian oral cancer?" — buccal mucosa, reflecting smokeless tobacco placement, in contrast to Western series where the tongue and floor of mouth dominate. Another is the description of ulcer margins: punched-out suggests aphthous or traumatic ulceration, undermined suggests tuberculosis, rolled and everted suggests squamous cell carcinoma. Candidates lose marks describing an ulcer without palpating the base — induration is a palpable sign, never a visual one — and by forgetting the gag reflex, which screens cranial nerves IX and X while completing the oropharyngeal survey.
Frequently asked questions
Which oral sites are considered high risk for cancer screening?
The buccal mucosa and retromolar trigone (especially with tobacco habits), lateral and ventral tongue, floor of the mouth, and the soft palate–tonsillar complex must be inspected and palpated at every examination.
Why is bimanual palpation preferred for floor-of-mouth lesions?
The sublingual tissues are examined with one finger intraorally and the other hand supporting the submandibular skin, so the full depth, mobility and tenderness of the lesion can be assessed from both sides.
What do everted ulcer margins with an indurated base indicate?
Classic for squamous cell carcinoma; induration extends beyond the visible margin, so the biopsy must include margin and adjacent mucosa.
How is the lateral border of the tongue examined?
The tongue is protruded, held with a piece of gauze and rotated towards the opposite side, exposing the lateral border and posterior reaches to direct vision and palpation.
What does the Oral Hygiene Index-Simplified measure?
Debris and calculus, each scored 0–3 on six selected surfaces, give a combined 0–6 score documenting oral hygiene objectively.