Dermatologic Therapy, Vol. 23, 2010, 209–219 © 2010 Wiley Periodicals, Inc.

Printed in the United States · All rights reserved

DERMATOLOGIC THERAPY
ISSN 1396-0296

The art and science of

oral examination dth_1318 209..219

Rania Agha* & Ginat W. Mirowski†

*Beeson Aesthetic Surgery Institute, Carmel, Indiana and †Department of
Oral Pathology, Medicine, Radiology, Indiana University School of Dentistry,
Indianapolis, Indiana

ABSTRACT: Performing an accurate oral examination is an integral part of a complete dermatological

evaluation. As dermatologists, we are frequently asked to assess and treat numerous oral pathologies,
which include, but are not limited to, normal variants, infections, ulcers, granulomas, lymphomas, as
well as primary and metastatic tumors of the mouth and lips. The oral mucosa can be the window
through which one can see and make numerous systemic diagnoses. Some clinicians are apprehensive
about performing this evaluation, or feel that this examination is outside of their realm of expertise.
These concerns may reflect limited exposure and education during training. Therefore, this article
aimed to educate the readers on how to complete an oral examination, demonstrate normal variants,
and highlight potential pitfalls and limitations of performing oral biopsies.

KEYWORDS: cervical lymphadenopathy, examination, head and neck exam, oral, oral biopsy, oral
nerve blocks

Introduction complete an oral examination, demonstrate

Performing an accurate oral examination is an inte-
gral part of a complete dermatological evaluation.
As dermatologists, we are frequently asked to
assess and treat numerous oral pathologies, which
include, but are not limited to, normal variants,
infections, ulcers, granulomas, lymphomas, as well
as primary and metastatic tumors of the mouth
and lips. The oral mucosa can be the window
through which one can see and make numerous
systemic diagnoses. Some clinicians are apprehen-
sive about performing this evaluation, or feel that
this examination is outside of their realm of exper-
tise. These concerns may reflect limited exposure
and education during training. Therefore, this
article aimed to educate the readers on how to
Address correspondence and reprint requests to: Ginat W.
Mirowski, DMD, MD, Adjunct Associate Professor, Indiana
University School of Dentistry, 10440 High Grove, Carmel, IN
46032, or email: gmirowsk@iupui.edu.
Financial disclosures: None.
normal variants, and highlight potential pitfalls
and limitations of performing oral biopsies.
The oral history
Before performing an oral examination, as in any
clinical assessment, a thorough history, including
dental and oral mucosal, should be obtained. The
nature and character of the lesions or condition
should be queried. Review of both over-the-
counter and prescription medications (topical as
well as systemic) is also important. Information
regarding the patient’s oral hygiene routine includ-
ing use (or lack thereof) of toothpastes, mouth-
washes, and habits; use of or ingestion of mints,
candies, sodas, tea, and coffee; and habits such as
tobacco chewing and smoking or use of illicit drugs
should be recorded. A complete review of systems,
as well as history of any previous dental and facial
cosmetic procedures or dental or facial implants
such as chin implants or other permanent hard-
ware, should be obtained.

209
Agha & Mirowski

FIG. 1. Vestibule.

In order to avoid omitting important aspects

of the oral examination, it is helpful to develop a
methodical, consistent, and organized approach.
Factors such as adjustable, bright white lighting
(using direct and/or overhead lights), and patient
positioning play a vital role in an accurate evalua-
tion. Both the patient and the physician should be
comfortable. For instance, the examination table
should be raised to a level which permits easy
viewing into the oral cavity. Secondly, the patient
should be reclined at approximately a 45-degree
angle, and the patient’s head should be stabilized
to limit movement to two planes (up/down and
left/right). Thus, the patient may be directed in
proper positioning and can participate actively in
the examination.
A complete oral examination includes both the FIG. 2. Full face evaluation in a patient who presented for
extra- and intraoral regions. The extraoral compo- Mohs. Note left cervical lymphadenopathy caused by intraoral
squamous cell carcinoma.
nent of the head and neck includes the face, eyes,
nose, cervical and pre-auricular lymph nodes,
thyroid gland, major salivary glands, lips, and of an overall assessment of the head and neck. The
angles of the mouth. The intraoral examination examiner should visually inspect for asymmetry;
includes the lips, vestibule, gingiva, buccal bony deformity; and gross abnormalities of the
mucosa, soft and hard palates, uvula, dorsal and head, face, orbits, nose, jaw, and neck. Special
ventral tongue, major and minor salivary glands, attention should be given to the pre-auricular
floor of the mouth, and oropharynx (1) (FIG. 1). cheeks and neck. Any asymmetry, erythema, or
Photographic documentation is an integral part other overlying skin changes, as well as masses,
of the dermatological medical records. Clinical should be noted and evaluated further (FIG. 2).
photographs may be especially useful in the oral With the patient seated in an upright (approxi-
examination for disease monitoring. Traditional mately 45 degrees) position, the examiner should
35 mm cameras that are designed to take intraoral palpate the neck one side at a time, specifically
pictures or newer digital cameras can be used for assessing for lymphadenopathy. Palpation should
these purposes. In our practice, we have found that always be performed in a systematic consistent
a variety of models deliver great-quality intraoral way (i.e., from superior to inferior or inferior to
pictures. superior). The cervical lymph node chains include
the pre-auricular, post-auricular, occipital, supe-
rior cervical, posterior cervical, submaxillary, sub-
The extraoral examination mental, inferior deep cervical, and supraclavicular
nodes (2). Supraclavicular lymphadenopathy may
The oral examination begins as soon as the physi- be facilitated when the patient performs the Val-
cian meets the patient. Initial evaluation consists salva maneuver (i.e., bears down) to increase

210

intrathoracic pressure. Unilateral nodes that are
fixed or immobile are suggestive of malignancy,
whereas bilateral, freely mobile, enlarged lymph
nodes are often associated with inflammation or
infection. Anterior cervical chain lymphadenopa-
thy is most commonly associated with inflamma-
tory or metastatic processes. Supraclavicular
lymphadenopathy is almost uniformly caused by
an underlying malignancy or tuberculosis (scrofu-
loderma). A careful lymph node survey is critical in
a complete body skin examination in patients with
suspected intraoral tumors or skin cancer, and
melanoma of the head and neck (3).
Next, the clinician should palpate the parotid
and submandibular glands for any masses. Some
benign tumors of the parotid glands, such as the
pleomorphic adenomas, have a potential for
malignant transformation of up to 9% (4,5). Parotid
gland neoplasms are best detected by deep palpa-
tion of the pre-auricular cheeks (4). Interestingly,
parotid gland neoplasms may be linked to cellular
phone usage as the prevalence of these neoplasms
has increased over the past decade (4).
The intraoral examination
The intraoral examination involves both visual
inspection, as well as superficial and deep palpa-
tion. All dentures, retainers, or mouth guards
should be removed prior to the examination, as
they may mask underlying pathology. Reinspection
with the appliances in place may reveal associate
trauma.
Moisture often alters the appearance of intraoral
lesions; therefore, it is helpful to use a small piece
of gauze (2 ¥ 2) to dry off the mucosa. In addition,
the gauze should be used to position and move the
tongue and lips for better visualization. The use of
cheek retractors (either metal or plastic) and dental
mirrors greatly facilitate visualization of the oral
cavity.
Minor trauma from normal activities such as
eating, drinking, and talking will alter the primary
morphology. In addition, a limited number of reac-
tion patterns reflect a long differential diagnosis.
The lips belong to both the intra- and extraoral
anatomic groups. The cutaneous aspect of the lips
is separated from the vermillion by the slightly
raised linear outline called the vermillion border.
The upper cutaneous lip is characterized by a
midline vertical groove called the philtrum. Later-
ally, the melolabial groove delineates the cutane-
ous lip from the adjacent cheek. The lateral
junction of the upper and lower lips occurs at the
commissures or angles of the mouth (1).
The art and science of oral examination
The patient should be asked to remove lipstick
or other lip emollients. With the mouth closed and
then open, the examiner should visually inspect
the lips and then palpate them using a bidigital
technique (i.e., between the thumb and index
finger). Specific attention should be given to color,
texture, and the presence of any growths or sec-
ondary lesions such as erosions, scale, and crust.
Normal lip markings are unique to each patient
and can be used to identify individuals much as
fingerprints on the tip of fingers. An early finding in
mild cheilitis (inflammation of the lips) is loss of
the markings caused by edema or inflammation.
The lips are the focus of numerous cosmetic
procedures, which include, but are not limited to,
lip augmentation, tattooing, laser hair removal,
and piercing. Dermal fillers used in lip augmenta-
tion can be a source of pathology such as sterile
granulomas, product nodules, or even necrosis (6).
Tattoos are occasionally used to accentuate the
vermillion and the vermillion border. Numerous
cutaneous diseases have been linked to lip tattoos;
they comprise granulomas, contact dermatitis,
squamous and basal cell carcinomas, and darken-
ing after laser exposure (7). Facial hair on the cuta-
neous lip varies depending on the age, sex, and
ethnicity of the patient. Medications (i.e., systemic
corticosteroids) and systemic disorders may be
associated with hypertrichosis. Unwanted facial
hair can be a source of psychological distress that
may drive women to seek treatment. A thorough
history and physical examination are essential in
evaluating a patient with hypertrichosis for under-
lying pathology such as hyperandrogenism, poly-
cystic ovarian syndrome, or malignancy (8).
The mucosal aspect of the lips is examined by
everting the lips, with special attention to the infe-
rior and superior labial frenula. Healthy intraoral
mucosa appears to be pink and moist. Mucinous
saliva produced by the minor salivary glands may
mask color, texture, and alterations of the underly-
ing mucosa; therefore, the examiner should dry off
the mucosa using gauze. An accurate lip examina-
tion may result in diagnosing numerous common
or important conditions. These include labial mel-
anotic macules; actinic, allergic, irritant, or angular
cheilitis; herpes labialis; Melkersson–Rosenthal
syndrome; cheilitis granulomatosa; squamous cell
carcinoma; and trichilemmomas, among many
others (9).
The buccal mucosa represents the inner aspects
of the cheeks. It can be visualized by gently stretch-
ing the cheek. This is accomplished by placing
one index finger inside the cheek at each of the
maxillary and mandibular alveolar sulci with the
211
Agha & Mirowski
patient’s mouth partially open. Nonpathological
variants include leukoedema, horizontal bite line,
and Fordyce spots (9). Leukoedema is a milky
whiteness which disappears upon stretching of the
mucosa. The bite line, also called linea alba, is a
linear hyperkeratosis that forms along the occlusal
aspect of the teeth and is caused by the repeated
suction or vacuum of the mucosa as one talks or
swallows (1). Fordyce spots, or ectopic sebaceous
glands, appear as small yellowish papules that are
found occasionally on the lips, but are found pre-
dominantly intraorally on the buccal mucosa (9).
Salivary glands are classified into major and
minor glands (1,2). The three paired major salivary
glands are the parotid, submandibular, and sublin-
gual glands. In contrast, minor salivary glands are
distributed throughout the oral cavity, especially
on the mucosal lips and the hard palate. Saliva
varies in its composition depending on the relative
percentage of acini that secrete aqueous or muci-
nous saliva. Obstruction of the minor salivary
gland ducts occurs commonly (1,10). Furthermore,
trauma to any salivary gland can result in accumu-
lation of mucinous saliva within the duct or
extravasation of saliva into the submucosa. Both of
these phenomena result in formation of mucoce-
les. Mucoceles are most common on the lower lip.
Minor salivary gland neoplasms which resemble
mucoceles are common on the anterior hard palate
(10).
The parotid gland should be palpated and
“milked” from its posterior aspect along the ramus
of the mandible to the anterior aspect of the cheek.
This results in the expression of clear aqueous
saliva from Stensen’s duct. Stensen’s duct appears
as a small pink papule located across from the
maxillary second molar in the superior aspect of
buccal mucosa (1) (FIG. 3). When Stensen’s duct is
occluded by a salivary stone, minimal saliva is
FIG. 3. Buccal mucosa with horizontal bite line. Stensen’s
duct is visible across from the maxillary second molar.
212
expressed, and the patient may complain of unilat-
eral cheek pain. Stensen’s duct is used as an ana-
tomical landmark when cosmetic buccal fat pad
extraction is performed (1,11).
To evaluate the palate, the patient is asked to tilt
his or her head upward and point the chin toward
the ceiling. This permits the clinician to view into
the oral cavity and use overhead lights. If focused
lights are available, they can further assist in illu-
minating the oral cavity. The use of a dental mirror
may also help when the reflection is directed onto
the mucosa. The mucosal aspect of the hard palate
is both firmly attached to the underlying bone and
heavily keratinized. Palatal rugae, which consist
of horizontal fibrous connective tissue, are located
on the anterior aspect of the hard palate (FIG. 4).
The incisive papilla lies just posterior to the
central incisor teeth, and represents an important
landmark as the exit point of the nasopalatine
neurovascular bundle (1). A midline bony protu-
berance, called the palatal torus, is seen in 5% of
the population (1,9,11). The anterior hard palate is
commonly traumatized by ingestion of hot foods
(i.e., pizza burn). Rarely, the hard palate fails to fuse
during embryogenesis, and a cleft palate may
result. The hard palate may rarely be the site of
neoplastic (i.e., minor salivary gland neoplasms)
and infectious processes (i.e., herpes simplex
infection) (9,11).
Posteriorly to the hard palate, the soft palate is
not associated with bone, but it is characterized by
the midline uvula that drapes in the posterior
FIG. 4. Hard palate. Thin red arrow points to the incisive
papillae, small white arrows point to the opening to the minor
salivary glands, and thick pink arrow directed to a small torus
palatinus.

oropharynx. The mucosa is orange-pink in color
and nonkeratinized (1,2). The soft palate is a
common site for Coxsackie virus infection, result-
ing in herpangina or hand–foot–mouth disease (9).
The presence of a bifid uvula may portend a sub-
mucosal boney cleft of the hard palate. Palpation of
the midline of the hard palate is indicated (1,2,11).
The teeth are embedded within the dental arch
of the palate and the mandible (1,2,11). These
arches are composed of alveolar bone and the over-
lying gingiva. At birth, the dental arch is typically
edentulous. This physiological edentulous state is
short lived. At approximately 7 months of age, the
primary dentition begins to erupt along the ante-
rior ridge and progressing posteriorly. Ultimately,
20 primary teeth will erupt over a period of 4–5
years. Even as the primary teeth are erupting, the
permanent dentition begins to develop deep
within the maxilla and the mandible. In children,
the ingestion of tetracycline is contraindicated
because tetracycline is deposited in the structure of
developing teeth, resulting in an irreversible disfig-
uring grayish blue discoloration (12,13). At around
6 years of age, the permanent dentition begins to
erupt, concluding with the eruption of the wisdom
teeth in early adulthood. The outer hard layer of the
teeth consists of white translucent enamel overly-
ing a softer, opaque yellow dentin. Caries result
when bacteria destroy the enamel, and then are
quickly spread into the dentin, ultimately entering
the cavity which houses the nerves and blood
vessels of the tooth.
Loss of teeth should prompt evaluation for
underlying pathology (12). Trauma, periodontal
disease, and dental carries are the most common
causes of tooth loss (14–16). Pathological causes of
tooth loss include Langerhans cell histiocytosis,
nutritional deficiency, rheumatoid arthritis,
dementia, and neuropathy. Chronic periodontal
disease may induce or exacerbate coronary artery
disease, peripheral vascular disease, diabetes,
hypertension, and asthma (14). Loss of tooth
enamel without loss of teeth is seen in bulimia or
severe gastroesophageal reflux disease (14–16).
The clinician should be aware of the normal
anatomy and appearance of the gingivae and ves-
tibule. The superior and inferior labial frenula
attach the lips and tongue, respectively, to the adja-
cent dental arches (FIG. 1) (1). The gingivae are
composed of the free and attached gingivae,
mucogingival junction line, and interdental papil-
lae (1). A normal healthy gingiva appears scalloped
with pointed interdental papillae (1). The attached
gingiva is firmly adherent to the underlying bone
and has a subtle stippled surface because of the
The art and science of oral examination
presence of submucosal fibrous bands that attach
the keratinized gingivae to the underlying bone (1).
In contrast, the free margin of the gingivae, a
1–3 mm rim of tissue located between the attached
gingivae and the tooth, is smooth (i.e., not
stippled). Acute necrotizing ulcerative gingivitis
(ANUG) is an acute bacterial infection that is char-
acterized by punched out necrosis of the interden-
tal papillae (9). This mixed bacterial infection is
commonly seen in young adults who are experi-
encing acute stress. Severe pain and a malodor are
characteristic of this disorder (9). Vitamin C defi-
ciency results in scurvy, and is associated with peri-
odontal bleeding and ANUG (17).
Physiological pigmentation of the attached
gingiva occurs in darker-skinned patients and pre-
sents as symmetric, uniform pigmentation varying
from light brown to black in color (18). Ethnic
variation in the color of the buccal mucosa is
uncommon. Gingival pigmentation may also be
caused by medications, neoplasms, and systemic
conditions. When evaluating pigmented lesions, an
oral biopsy and thorough review of systems may
help with accurate diagnosis (see the article by Dr.
Muller) (1). Deposition of minocycline may appear
as a blue discoloration of the attached gingiva, but
this is actually caused by deposition of the drug in
the underlying bone (12).
Oral cancer is increasing in incidence and
carries significant morbidity and mortality (19).
The lateral tongue and floor of the mouth are the
most common sites for oral cancer. It is imperative
that physicians familiarize themselves with the
normal anatomy and appearance of these two
important mucosal sites. To examine the tongue,
the patient should be asked to extend or protrude
the tongue, whereas the examiner gently but firmly
grips the anterior of the tongue between the thumb
and index fingers using a 2 ¥ 2 gauze. The dorsal,
ventral, and lateral aspects of the tongue should be
inspected carefully. Only the anterior two-thirds
of the tongue is visible clinically; the posterior
one-third, or base, of the tongue is visible using a
laryngoscope. The different characteristics and
innervations of the anterior and posterior aspects
of the tongue are rooted in their distinct embryo-
logical origins. Vascular dilatation is commonly
seen on the lateral aspect of the tongue.
The dorsal surface of the tongue is covered with
both filiform and fungiform papillae (FIG. 5). The
extensive filiform papillae appear as small white or
yellow hairlike projections. The fungiform appears
as mushroom-like papillae that are relatively
scarce, red or pigmented, rounded papules, and are
distributed among the filiform papillae. The dorsal
213
Agha & Mirowski
FIG. 5. Dorsal tongue with filiform and fungiform papillae.
tongue is heavily keratinized, whereas the ventral
tongue is not; the lateral borders are parakerati-
nized (1,2). The terminal sulcus and the circumval-
late papillae are arranged in an inverted “V” with
the apex of the “V” pointing to the foramen cecum
(the initial point of the thyroglossal duct that is
formed as the thyroid gland descends into the neck
during embryogenesis). The terminal sulcus (a
shallow groove that extends from the foramen
cecum laterally and anteriorly on either side) sepa-
rates the posterior one-third and the anterior two-
thirds of the tongue (1,2). Geographic tongue
(benign migratory glossitis), fissured tongue, and
papillitis are typically seen on the dorsal surface.
Complete loss of the filiform papillae (atrophic
glossitis) is seen in severe vitamin B deficiencies
(1,9,18).
The lateral borders of the tongue are pink and
shiny, with occasional vertical superficial fissures
(foliate papillae) particularly in the posterior
region. Lingual tonsils are located at the posterior–
lateral base of the tongue and may enlarge because
of local inflammation, infection, or neoplasia (1).
Saliva tends to pool against the lateral borders of
the tongue. Therefore, exogenous agents such as
tobacco and alcohol may accumulate, resulting in
higher incidence of tongue cancer at the lateral
border (19). Oral hairy leukoplakia presents with
214
corrugated white vertical ridges on the lateral
border of the tongue. Oral hairy leukoplakia is
associated with Epstein–Barr virus and is seen in
patients with HIV disease or other immunosup-
pressed states (9,18).
The mucosa of the ventral tongue is thin, non-
keratinized, and lacks papillae (1,11). Therefore,
the sublingual veins easily visualized. The ventral
tongue should be visually inspected for physiologi-
cal variants (such as varices and fimbriae) or
pathological findings. The tongue is attached to the
floor of the mouth via the lingual frenulum. Whar-
ton’s ducts (ostia of the submandibular salivary
glands) are located laterally on both sides of the
lingual frenulum (1,11). Clear saliva can be
expressed by bimanual palpation of the subman-
dibular glands (i.e., placement of two to three
fingers at the submandibular neck, milking the
gland using a forward stroking motion, and visually
inspecting the floor of the mouth/ventral tongue.
Patients with Ehlers–Danlos lack a lingual frenu-
lum and therefore are able to touch the tip of their
nose with their tongue (Gorlin sign) (9,18). When
the frenulum is foreshortened or over-attached,
“tied tongue” results (1).
The floor of the mouth is the most common site
of oral cancer (9,11,18). Visual examination
requires retraction of the tongue, and palpation
should be performed bimanually with an index
finger pressing downward intraorally while the
contralateral hand is placed gently under the chin
pressing upward.
The oral biopsy
As noted above, oral exam is easily accomplished
and may be essential in evaluation of patients with
mucocutaneous and system diseases. Obtaining a
biopsy early in the course of oral diseases allows
one to diagnose precancerous conditions, improve
prognosis, and minimize morbidity and mortality.
Collaboration between the dermatologist, dentist,
oral maxillofacial surgeon, and oral pathologist is
essential to an optimal outcome for oral biopsies.
Indications to perform an oral biopsy include, but
are not limited to, lesions that persist for more than
3–4 weeks, lesions that are clinically suspicious for
malignancy, inflammatory conditions (such as oral
lichen planus), bullous lesions (such as may occur
in cicatricial pemphigoid and pemphigus vulgaris),
and pigmented lesions of unknown etiology
(1,2,9,11,18). Contraindications to performing an
oral biopsy include serious illness, microstomia
(may limit access), bleeding diatheses, coagulopa-

thies, and severe gag reflex (may limit access
during the procedure and may be associated with
increased risk of emesis or aspiration) (20).
In the outpatient setting, biopsies should not be
performed at sites that are deep or are in proximity
to important structures, such as Stensen’s duct,
posterior soft palate, or the floor of the mouth. In
addition, it is advisable to avoid biopsying sus-
pected vascular lesions (given the risk of excessive
bleeding), multiple neurofibromas (because of the
risk of possible transformation to neurosarcoma),
and tumors of the greater salivary glands. Such
cases may be referred to otolaryngologists or oral
surgeons (20).
In general, when the anatomy is well understood
and pitfalls are avoided, an oral biopsy is a safe and
reliable diagnostic tool. Some invasive procedures
may result in bone formation and should not be
performed if possible, especially in patients receiv-
ing injectable bisphosphonates. In fact, mucosal
lesions in such patients may indicate an underlying
osteonecrosis, which may be worsened by any
iatrogenic trauma/exploitation (21).
Several parties are involved in an oral biopsy,
and their goals are not identical. The patient’s
main concerns are for the biopsy to be quick and
painless, with minimal postoperative discomfort
and diagnostic. The surgeon would like the biopsy
also to be quick, simple, safe, and free of compli-
cations. The pathologist, on the other hand,
always appreciates an excision or representative
undamaged specimen labeled with the specific
anatomical site. Therefore, the surgeon carries the
responsibility of ensuring that all parties involved
are satisfied.
Preparation for the biopsy
It is important to obtain a careful and thorough
informed consent. The patient’s questions and
concerns should be addressed in lay terms.
Patients should be queried specifically about
current medications, drug allergies, and medical
comorbidities including bleeding diatheses,
history of malignant hypertension, immunosup-
pression, pulmonary disease, and prosthetic heart
valves and joints.
The American Heart Association has issued rec-
ommendations regarding the use of antibiotic pro-
phylaxis in patients with cardiac and/or joint
prostheses (22). Prophylactic antibiotic adminis-
tration is necessary for patients with prosthetic
cardiac valves or prosthetic material used for
cardiac valve repair, previous infective endocardi-
The art and science of oral examination
Table 1. Recommendations of the American Heart
Association for antibiotic prophylaxis doses for
dental procedures: single dose 30–60 minutes
before procedure (modified from (22))
Drug Adult dose Route
Amoxicillin or ampicillin 2g PO
Amoxicillin or ampicillin 2g IV or IM
Cefazolin or ceftriaxone 1g IM or IV
Cephalexina 2g PO
Clindamycina 600 mg PO
Azithromycin or clarithromycina 500 mg PO
Cefazolin or ceftriaxoneb 1g IV or IM
Clindamycinb 600 mg IV or IM
a
Allergic to penicillin or ampicillin.
b
Allergic to penicillin or ampicillin, and cannot take PO
meds.
tis, congenital heart disease, unrepaired cyanotic
congenital heart disease, completely repaired con-
genital heart defect with prosthetic material or
device for the first 6 months after the procedure,
repaired congenital heart defect with residual
defects, and cardiac transplant recipients who
develop cardiac valvulopathy (22). Prophylaxis
should be aimed to prevent infection with Strepto-
coccus viridans. In general, amoxicillin is the drug
of choice. Penicillin-allergic patients may alterna-
tively receive cephalexin, clindamycin, azithromy-
cin, or clarithromycin (22) (Table 1).
The use of anticoagulants may contribute to
increased peri- and postoperative bleeding.
Aspirin irreversibly inhibits platelet aggregation
for the lifespan of the platelets (6–10 days).
Patients who are not at a risk of myocardial inf-
arction or stroke may discontinue aspirin 1 week
prior to the oral biopsy. Other nonsteroidal
agents, such as ibuprofen and naproxen, revers-
ibly inhibit platelet aggregation and should be dis-
continued 1–4 days prior to oral surgery. Warfarin,
on the other hand, may be continued, if the inter-
national normalized ratio is between 2 and 3. Any
discontinuation of warfarin therapy prior to oral
biopsy should be performed under the supervi-
sion of the warfarin-prescribing physician.
Warfarin may be restarted on the evening of the
oral surgery (18).
Prior to the biopsy, another careful survey of
the submandibular, sublingual, supraclavicular,
and posterior cervical lymph nodes should be
performed (2). Lymphadenopathy, or lack thereof,
should be documented in all cases where a neo-
plasm is considered, as this is critical for accurate
staging of squamous cell carcinoma and other
oral tumors. The surgeon should confirm with the
215
Agha & Mirowski

Table 2. Regional blocks

Nerve Region anesthetized
Infraorbital nerve Upper lip, medial cheek,
nasal ala
Mental nerve Lower lip, parts of the chin
Lingual nerve Anterior two-thirds of
tongue, lingual surface
of mandibular gingiva
Inferior alveolar nerve Body of mandible, lower
(posterior division of portion of ramus, all
marginal mandibular mandibular teeth, floor
nerve) of the mouth, anterior
two-thirds of tongue,
gingivae on lingual surface
of the mandible, gingivae
on labial surface of
mandible, mucosa and
skin of lower lip and chin

patient again that there are no contraindications,

as listed above, to performing the biopsy.

The biopsy procedure

Patient positioning is usually the same as described
above for the oral exam. The exam table should be
raised to a height comfortable for the surgeon and
assistant. The biopsy site should be easily visual-
ized and accessible equally to both the surgeon and
surgical assistant.
Local anesthesia can be obtained by direct
infiltration of the biopsy site, with regional blocks,
or rarely, with topical application (benzocaine).
Regional blocks and the sites that anesthetize with
each are presented in Table 2. Infiltration of 1%
lidocaine with 1 : 100,000 epinephrine is per-
formed with a 0.5- to 1-inch 30-gauge needle. For
instance, an infraorbital nerve block is achieved
when a needle is inserted between the first and
second premolars, then slowly advanced superi-
FIG. 6. (a) Infraorbital nerve block with needle in the
orly along the periosteum until bone is reached. infraorbital foramen. (b) Infraorbital nerve block thorough
The needle is then retracted slightly, and the anes- the intraoral approach.
thetic is slowly injected. For mental blocks, a 0.5-
inch 30-gauge needle can be inserted between the
first and second premolars inferiorly along the biopsy are the mucogingival junction, lips, and
periosteum to a midpoint down the mandible. loosely attached mucosa (i.e., buccal and labial
Anesthetic is then slowly injected (18,20). Figures mucosa) (20). When performing a biopsy, obtain-
6 and 7 illustrate infraorbital and mental nerve ing tissue from the attached gingiva is preferable
blocks, respectively. to the marginal gingiva. This will minimize the risk
Vital structures, such as major salivary gland of developing permanent gingival defects. Damage
ducts, need to be avoided. The areas with the to the thin underlying alveolar bone results in a
lowest risks of scarring or uncontrolled bleeding to cosmetic defect (1,20).

216
 The art and science of oral examination

FIG. 8. Oral biopsy surgical tray.

Table 3. Risks associated with anatomical biopsy

sites
Anatomic site Risks of biopsy
Lips: philtrum, Poor cosmesis caused by crossing
angle of anatomical cosmetic subunit
mouth,
vermilion
border
Free gingiva Poor cosmesis caused by bone loss
Buccal mucosa at Laceration of the parotid duct
Stensen’s duct requires microsurgery for repair
Floor of mouth Ranula formation, airway
obstruction
Ventral tongue Lingual vein injury
Posterior tongue, Aspiration, airway obstruction,
soft palate, hemorrhage, gag reflex
uvula,
epiglottis

FIG. 7. (a) Mental nerve block showing the mental nerve.
(b) Demonstration of mental block.
Oral biopsy techniques are similar to those used
for skin, and include incisional, excisional, punch,
snip, and shave biopsies (1,20). Except for the cha-
lazion clamp, identical instruments can be used for
the skin and oral biopsy. The chalazion clamp is
used to aid with hemostasis for biopsies of the lip,
tongue, and buccal mucosa (1). Figure 8 shows a
typical oral biopsy tray.
Specimens are placed in formaldehyde for
routine H&E and special stains (i.e., routine immu-
nohistochemistry, stains for microorganisms), in
Michel’s medium (or normal saline) for immunof-
luorescence, sterile saline without preservatives for
tissue culture, and Hanks medium for viral studies
(1). Analogous to having dermatopathologist read
skin biopsies, the specimen should ideally be sent
to oral pathologist or a specialist trained in reading
oral biopsies.
Avoiding pitfalls
Oral biopsy should be not be performed at sites of
vital structures (i.e., Stenson’s duct, neurovascular
bundle at the incisive papillae), highly vascular
sites (i.e., floor of the mouth), and sites that cannot
be easily visualized and/or accessed (i.e., posterior
one-third of the tongue, soft palate, uvula, and epi-
glottis), Stensen’s duct, retromolar trigone, and
soft palate. Table 3 summarizes biopsy sites and
associated risks. Aspiration, airway obstruction, or

217
Agha & Mirowski
swallowing of the specimen by the patient are also
associated risks (1,11,20).
Biopsies and other procedures of the lips that
cross the vermilion border or involve the philtrum
or angles of the mouth may result in significantly
poor cosmesis. Orientation of the biopsy along the
natural lip lines or skin markings generally results
in a more favorable cosmetic outcome. When using
a punch biopsy, retracting the mucosa perpendicu-
lar to the lip folds results in an oval defect that is
conducive to orienting the closure along the lip
folds and minimizing scarring (1,11,20).
Tongue biopsies are more complicated, and the
technique used should be chosen based on the
clinical differential diagnosis and specific anatomi-
cal location. Consideration of the depth of the
pathology will influence what technique is needed
and what approach should be used. In general, the
tongue is highly vascular because of the underlying
muscle. Use of the punch technique may be limited
by the associated difficulty in achieving an ellipse
and in limiting the biopsy depth to the mucosal
aspect. Generally, tongue biopsies are more easily
accomplished using a surgical blade (#15), which
allows the surgeon to stay superficial and orient an
ellipse along the lateral tongue margins (20). On
the ventral surface of the tongue, the lingual veins
should be avoided. Given the vascularity and diffi-
culty in obtaining hemostasis, biopsies of the
ventral tongue should probably be referred to a
surgeon. In the case of papillomas of the lingual
frenulum, a shave or snip technique can be easily
performed (20).
Minor salivary gland biopsy
A biopsy of the labial minor salivary glands is rou-
tinely performed to diagnose xerostomia associ-
ated with Sjögren’s syndrome. A chalazion clamp
is used to retract the labial mucosa (FIG. 9). A
linear incision, 1–1.5 cm, is made in a vertical ori-
entation. Then, using thin iris scissors and with
the point up, six or more salivary gland lobules
that may appear to extrude are gently dissected.
These 1–3 mm minor salivary gland lobules
appear as pale gray or yellow papules. In order to
limit post-procedure mucocele formation (which
can result when a minor salivary gland is trauma-
tized), the clinician should visually confirm that
no salivary gland fragments remain within the
incision site.
A variety of hemostasis techniques can be uti-
lized during oral mucosal biopsies. Pressure can be
applied; pressure may not, however, be adequate
218
FIG. 9. Chalazion clamp placed on lower lip in preparation
for minor salivary gland biopsy.
for hemostasis of tongue biopsies because of the
extensive vascularity of the tongue muscle. Other
methods, such as the use of gel foam, cautery, CO2
laser, and suturing, will aid in achieving adequate
hemostasis. The authors prefer monofilament
nylon sutures over silk and gut sutures because of
the fact that nylon is easier to use and is less irri-
tating than either silk or gut.
Complications of oral biopsies include bleeding,
sensory impairment, dehiscence, and rarely infec-
tion. Certain complications are specific to the site
of the biopsy. For instance, mucoceles may develop
after biopsying minor salivary glands of the labial
mucosa, and ranulas (mucoceles of the major sali-
vary glands) may develop in the floor of the mouth.
Plunging ranulas can result in acute airway
obstruction as the ranulas may extend thorough
the mylohyoid muscle into the anterior neck
region. Biopsying a plunging ranula may result in
hemorrhage, lingual nerve and submandibular
duct injury (resulting in stenosis or sialadenitis),
ductal laceration (leading to salivary leakage), and
even acute airway obstruction (21). The authors
highly recommend that the presence of a ranula be
considered a medical emergency that would be
best evaluated when the airway can be maintained.
Thus, no biopsies should be performed in the
floor of the mouth unless airway management is
available.
Biopsies of the hard palate and maxillary arch
may induce local discomfort to the patient. The
infiltration of local anesthetic into the hard palate
is painful. A punch biopsy is the ideal technique;
however, a periosteal elevator may be needed.
Prior to biopsying the hard palate, the surgeon
should palpate to confirm that there is no submu-

cosal cleft in the midline. Boney prominences,
such as torus palatinus, as well as the incisive
papilla, should be avoided (20). In the case of a
swelling in the anterior midline or the palate, the
clinician should suspect an incisive canal cyst. An
occlusal radiograph should be obtained prior to
biopsy.
In summary, oral biopsies can be safely per-
formed when the surgeon is aware of the anatomy
of the oral cavity; knows which areas not to biopsy;
and most importantly, has adequate support in
case of unexpected outcomes.
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