Extraoral and Intraoral Examination

Core Review

Examination Principles

The extraoral and intraoral examination is performed as part of every comprehensive and periodic assessment. It serves three primary purposes: (1) oral cancer screening, (2) identification of conditions requiring treatment or referral, and (3) establishment of a baseline for future comparison. The examination must be systematic, thorough, and documented.

Equipment needed: Good lighting, mouth mirror, 2×2 gauze, gloves, and possibly a tongue depressor or periodontal probe for further investigation of lesions.

Sequence matters: The NBDHE expects a specific, reproducible sequence. Develop a consistent routine that covers every structure — this ensures nothing is missed.

Extraoral Examination

The extraoral examination proceeds in a head-to-toe sequence:

1. General Appearance and Inspection Observe the patient's overall appearance, posture, gait, and any visible asymmetry. Note skin color, lesions, scars, or obvious swelling. Does the patient appear well-nourished? Are there signs of systemic disease (jaundice, pallor, cyanosis)?

2. Head and Face Inspect the head for size, shape, and symmetry. Note any facial asymmetry that may indicate swelling, masses, or neuromuscular disorders. Palpate the facial bones (frontal, zygomatic, maxillary, mandibular) for tenderness or irregularities.

3. Temporomandibular Joint (TMJ) Assessment

• Inspection: Observe jaw opening for deviation or deflection. Deviation (returns to midline) suggests disc displacement with reduction. Deflection (stays to one side) suggests disc displacement without reduction.
• Palpation: Palpate the TMJ bilaterally by placing fingers just anterior to the tragus of the ear. Ask the patient to open and close slowly. Note clicking (disc displacement with reduction), crepitus (degenerative changes), or tenderness.
• Auscultation: Listen for joint sounds with a stethoscope placed over the joint area.
• Range of motion: Normal maximum opening is 40-60 mm (approximately 3 finger-widths). Lateral excursive movements should be approximately 8-10 mm. Limited opening (<35 mm) may indicate disc displacement without reduction or muscle trismus.
• Muscles of mastication: Palpate the masseter (superficial and deep), temporalis, and medial pterygoid muscles for tenderness. The lateral pterygoid is not directly palpable but can be assessed through resisted protrusion.

4. Lymph Nodes Lymph node examination is critical for detecting infection, inflammation, and metastatic disease. Palpate using the pads of the second, third, and fourth fingers with gentle circular motions. The NBDHE expects you to know the location and drainage of each node group.

Systematic lymph node palpation sequence:

• Occipital nodes: Base of the skull posteriorly. Drain the posterior scalp.
• Postauricular (mastoid) nodes: Behind the ear over the mastoid process. Drain the external ear and scalp.
• Preauricular nodes: Anterior to the tragus of the ear. Drain the eyelids, external ear, and parotid gland.
• Parotid nodes: Within the parotid gland region.
• Submandibular nodes: Beneath the body of the mandible. Drain the cheeks, lips, tongue, floor of mouth, submandibular and sublingual glands. This is the most common site for metastatic oral cancer to first appear.
• Submental nodes: Beneath the chin, midline. Drain the chin, lower lip, floor of mouth, and tip of tongue.
• Anterior cervical nodes: Along the anterior border of the sternocleidomastoid muscle. Drain the anterior neck region.
• Posterior cervical nodes: Along the posterior border of the sternocleidomastoid muscle. Drain the posterior scalp and neck.
• Supraclavicular nodes: Above the clavicle. Enlargement may indicate thoracic or abdominal malignancy (Virchow's node on the left side).

Normal vs Abnormal Lymph Nodes:

• Normal: Soft, mobile, non-tender, <1 cm, often not palpable
• Infection/Inflammation: Enlarged, tender, mobile, firm but not hard
• Malignancy: Hard, fixed (non-mobile), non-tender, may be matted together

5. Thyroid Gland Palpate the thyroid gland by standing behind the patient or facing them. Place fingers over the lower anterior neck and ask the patient to swallow — the thyroid gland should move upward. Note any enlargement (goiter), nodules, or tenderness.

6. Salivary Glands Palpate the parotid glands (anterior to and below the ear) and submandibular glands (beneath the mandible, medial). Glands should be soft and not tender. Enlargement may indicate infection, obstruction (sialolithiasis), autoimmune disease (Sjögren syndrome), or neoplasm.

Intraoral Examination

The intraoral examination follows a posterior-to-anterior sequence to avoid contaminating posterior structures with anterior secretions:

1. Lips and Vermilion Border Inspect with the mouth closed and open. Note color, texture, moisture, and any lesions. The vermilion border of the lower lip is a common site for actinic cheilitis (sun damage) and squamous cell carcinoma. Palpate the lips bidigitally (index finger inside, thumb outside) to detect submucosal masses.

2. Labial Mucosa and Vestibule Retract the lips and cheeks. Inspect the maxillary and mandibular vestibules, noting the mucobuccal fold, frenum attachments, and any lesions. The labial mucosa should appear pink, moist, and smooth. Fordyce granules (ectopic sebaceous glands) are common normal variants appearing as small yellow papules.

3. Buccal Mucosa Retract the cheek and inspect from the commissure posteriorly to the retromolar area. Note the parotid papilla (Stensen's duct) adjacent to the maxillary first molar — it should appear as a small, pink elevation. Linea alba (white line along the occlusal plane) is a common normal variant from chronic cheek biting.

4. Hard Palate Inspect with the patient's head tilted back. Note color (pink), contour, and any torus palatinus (bony exostosis in the midline — a common normal variant). The incisive papilla is located behind the maxillary central incisors. Rugae are the transverse ridges in the anterior palate.

5. Soft Palate and Oropharynx Depress the posterior tongue with a mouth mirror and ask the patient to say "ah" — this elevates the soft palate and allows visualization. Note symmetry of movement (cranial nerve X — vagus nerve). The uvula should elevate in the midline. Asymmetry may indicate neurologic deficit. Note the tonsillar pillars and any tonsillar tissue.

6. Tongue — Dorsal Surface Grasp the tongue with a 2×2 gauze and gently extend it. Inspect the dorsal surface, noting the filiform papillae, fungiform papillae, and circumvallate papillae (8-12 large papillae in a V-shaped row at the junction of the anterior two-thirds and posterior one-third). Note any coating, variation in color (geographic tongue, hairy tongue), or lesions.

7. Tongue — Lateral Borders This is the MOST COMMON site for oral squamous cell carcinoma. Grasp the tip with gauze and move the tongue to each side. Inspect the entire lateral border from posterior to anterior. Palpate for induration (hardening) or masses. The lateral and ventral surfaces of the tongue account for approximately 50% of all oral cancers.

8. Tongue — Ventral Surface Ask the patient to touch the tongue tip to the roof of the mouth. Inspect the ventral surface, noting the lingual frenum, sublingual caruncles (Wharton's ducts from the submandibular glands), and the plica fimbriata (fringed folds lateral to the frenum). Note any varicosities (lingual varices — common normal variant in older adults).

9. Floor of Mouth This is the SECOND most common site for oral squamous cell carcinoma. Inspect and bidigitally palpate (one finger intraorally, one extraorally under the chin). The floor of the mouth should feel soft and pliable. Induration or masses warrant immediate referral.

10. Gingiva and Alveolar Mucosa Inspect the facial and lingual gingiva of both arches. Note color (coral pink, may be pigmented), contour, consistency, and any lesions. The attached gingiva should be firm and stippled. Examine for gingival recession, enlargement, or ulceration.

Documentation

All findings must be documented precisely:

• Location: Use anatomical descriptors (e.g., "right lateral border of tongue, posterior third")
• Size: Measure with a periodontal probe (in millimeters)
• Color: Erythematous, white, pigmented, mixed
• Surface texture: Smooth, rough, papillary, verrucous, ulcerated
• Consistency on palpation: Soft, firm, hard, indurated
• Mobility: Fixed or mobile relative to underlying tissues
• Symptoms: Pain, tenderness, paresthesia, bleeding

High-Risk Findings Requiring Immediate Referral

• Any non-healing ulcer present for >2 weeks
• Erythroplakia (red patch) — highest malignant transformation risk
• Leukoplakia (white patch that cannot be wiped off)
• Indurated (hard) mass or ulcer
• Unexplained bleeding
• Paresthesia or numbness
• Fixation of tissue to underlying structures
• Enlarged, hard, fixed lymph nodes
• Difficulty swallowing (dysphagia)
• Persistent hoarseness

Oral Cancer Statistics

• Oral and pharyngeal cancer: approximately 54,000 new cases annually in the US
• Approximately 11,000 deaths annually
• 5-year survival rate: approximately 66% overall but varies dramatically by stage
• Early stage (localized): 5-year survival >84%
• Late stage (distant metastasis): 5-year survival <40%
• Risk factors: tobacco (all forms), alcohol (synergistic with tobacco), HPV-16 (oropharyngeal), sun exposure (lip), age >40, male gender

Clinical Application

During a periodic examination of a 58-year-old male with a 30-pack-year smoking history, you identify a 6 mm × 4 mm mixed red-and-white lesion on the right lateral border of the tongue. The patient reports he "wasn't aware of it." On palpation, the lesion feels slightly firm compared to surrounding tissue. There is a palpable, mobile, slightly tender right submandibular lymph node.

This presentation — mixed red/white lesion (erythroleukoplakia) on the lateral tongue in a tobacco user with ipsilateral lymphadenopathy — is highly suspicious for dysplasia or carcinoma. Immediate referral to an oral surgeon or oral medicine specialist for biopsy is indicated. Document the lesion's location, size, color, and palpation findings. Schedule a follow-up to confirm the patient completed the referral.

Common Traps

• TRAP: Confusing Fordyce granules with pathology. These ectopic sebaceous glands are normal variants.
• TRAP: Confusing linea alba with leukoplakia. Linea alba is located along the occlusal plane and is caused by chronic friction.
• TRAP: Confusing torus palatinus or torus mandibularis with neoplasm. Tori are benign bony exostoses that are typically bilateral (mandibular tori) or midline (palatal torus).
• TRAP: Failing to palpate. Visual inspection alone misses submucosal masses and induration.
• TRAP: Forgetting to examine the lateral borders of the tongue. This is the most common site for oral cancer, yet it is easily overlooked.
• TRAP: Not asking the patient about lesions they may not have noticed. Many early oral cancers are asymptomatic.