Skill: Assessing the Mouth and Oropharynx

Performed
Preparation Yes No Mastered Comments
1. Assemble equipment and supplies:
 Clean gloves
 Tongue depressor
 2 x 2 gauze pads
 Penlight
Procedure
1. Introduce yourself and verify the
client’s identity. Explain to the
client what you are going to do,
why it is necessary, and how she
can cooperate.
2. Perform hand hygiene and observe
other appropriate infection control
procedures.
3. Provide for client privacy.
4. Inquire if client has any history of
the following:
 Routine pattern of dental care
 Last visit to dentist
 Length of time ulcers or other
lesions have been present
 Any denture discomfort
 Any medications the client is
receiving
5. Position the client comfortably—
seated, if possible.
Assessment

Lips and Buccal Mucosa

6. Inspect the outer lips for symmetry
of contour, color, and texture.
Ask the client to purse lips as if to
whistle.
7. Inspect and palpate the inner lips
and buccal mucosa for color,
moisture, texture, and the presence
of lesions.

Teeth and Gums

8. Inspect the teeth and gums while
examining the inner lips and buccal
mucosa.
9. Inspect the dentures.
Ask the client to remove complete or
partial dentures. Inspect their
condition, noting in particular broken
or worn areas.
 Tongue/Floor of the Mouth
10. Inspect the surface of the tongue
for position, color, and texture.
Ask the client to protrude the tongue
and move it from side to side.
11. Inspect tongue movement.
Ask the client to roll the tongue
upward and move it from side to side.
12. Inspect the base of the tongue, the
mouth floor, and the frenulum.
Ask the client to place the tip of his
tongue against the roof of the mouth.
13. Palpate the tongue and floor of the
mouth for any nodules, lumps, or
excoriated areas.
Use a piece of gauze to grasp the tip
of the tongue and, with the index
finger of your other hand, palpate the
back of the tongue, its borders, and its
base.

Salivary Glands
14. Inspect salivary duct openings for
any swelling or redness.

Palates and Uvula

15. Inspect the hard and soft palate for
color, shape, texture, and the
presence of bony prominences.
Ask the client to open mouth wide
and tilt head backward. Then, depress
tongue with a tongue blade as
necessary, and use a penlight for
appropriate visualization.
16. Inspect the uvula for position and
mobility while examining the
palates.
To observe the uvula, ask the client to
say “ah” so that the soft palate rises.

Oropharynx and Tonsils

17. Inspect the oropharynx for color
and texture.
Inspect one side at a time to avoid
eliciting the gag reflex. To expose
one side of the oropharynx, press a
tongue blade against the tongue on
the same side about halfway back
while the client tilts head back and
opens mouth wide. Use a penlight for
illumination, if needed.
18. Inspect the tonsils for color,
discharge, and size.
19. Elicit the gag reflex by pressing the
posterior tongue with a tongue
blade.
20. Document findings in the client
record.