Assessment of The Mouth

Procedure How to perform Normal Abnormal

1.) Assess the smell of - You should stand at - Breath should smell - Smells like ammonia;
the breath of the least 12 inches away fresh. usually associated
patient. from your client while with kidney disease.
smelling the breath. - Acetone breath; this
can be a sign of
diabetes.
- Halitosis or bad breath
2.) Inspect the lips for: - When inspecting you - It should be PINK in - Presence of angular
COLOR, MOISTURE, should stand at least color cheilosis; dryness on
INTEGRITY, and 12 inches away from - It should be MOIST the sides of the lips.
SWELLING the client. - There is no presence - Presence of lesions
of lesions - Inflamed/swollen
- There are no - Pale in color
inflammations - Cyanotic
- There are cracks
3.) Inspect the oral cavity - Ask the client to open - For the gums: - For the gums:
(gums, buccal his/her mouth and • No swelling • Gingivitis (tender,
mucosa, hard and soft inspect using a tongue • No bleeding red, swollen and bleed
palate) depressor and a • Gum margins is well easily)
penlight. defined with no pocket • Addison’s disease
existing between the (brownish gums)
gums and the teeth • Periodontitis
•For light-skinned (Purulent drainage
clients: gums are pale may be present. The
red stippled surface gingival borders are
•For dark-skinned red and infection of
clients: patchy brown pocket formed
pigmentation between receding
- For the buccal gums and teeth.)
mucosa:
• No lesions - For buccal mucosa:
• It is smooth • Xerostomia (dryness
• Moist of the mucosa)
• There might be a • Pale mucosa
freckle-like macules • Leukoplakia
may appear inside (leathery, painless,
 Assessment of The Mouth

- For the hard and soft white painted-looking

palate: patches)
• Hard palate has - For the hard and soft
many ridges palate:
• Soft palate is • Presence of lesions
smooth • It is swollen
• There are no lesions • It is tender
• There are no signs • There is a presence
of inflammation and of infection
infection • Torus Palatinus
• It should be concave (bony ridges in the
• It should be pink midline of hard palate)

4.) Inspect the teeth for: - Ask the client to open - 32 teeth are present - Missing or absent
(number, color, his/her mouth and - White to yellowish teeth
alignment, presence inspect using a tongue color - Presence of dental
of dental appliances, depressor and a - Has smooth edges carries or tooth decay
and decay) penlight. - Properly aligned - Presence of dead
- There should be no tooth
decay or carries
5.) Inspect the uvula - Ask the client to open - It is in the midline - Presence of lesions
his/her mouth and - There is no swelling - Presence of exudates
inspect using a tongue - There is no exudate - Color is pale
depressor and a - There are no lesions - Inflamed/swollen
penlight. - It should be pink in
color
6.) Test for the motor - Instruct the patient to - For the CN IX - For the CN IX
nerve function of CN say “AHHHHHH” for (Glossopharyngeal (Glossopharyngeal
IX and X CN IX. Ask the patient nerve): nerve):
(Glossopharyngeal to swallow for CN X. • The uvula should be • The uvula isn’t able
and Vagus nerve) Then use a penlight to able to rise and fall to rise and fall
inspect. - For the CN X (Vagus - For the CN X (Vagus
nerve): nerve):
• Swallows easily • Painful and has
difficulties when
swallowing
7.) Check for the gag - Using a tongue - There should be a gag - There is no gag reflex
 Assessment of The Mouth

reflex depressor gently reflex

stroke the posterior
part of the mouth
8.) Inspect the tonsils for: - Instruct the patient to - Tonsils should be pink - There is an exudate
(color, grade, open his/her mouth - It should be grade 1+ - It is swollen
presence of exudates) and inspect using a or 2+ - There is a viral
penlight - There should be no pharyngitis and
exudates tonsillitis (posterior
pharynx is red and
with white patches.
Tonsils are larger and
red with white
patches)
- The tonsils are grade
3+ or 4+
9.) Inspect the tongue - Instruct the patient to - It is symmetrical - The tongue is
for: (Symmetry, open his/her mouth - It is moist deviated
position, and presence and inspect using a - It should be rough - Candidiasis (a thick,
of lesions) penlight - There are no lesions white curd-like coating
- It should be located at on tongue)
the midline of the - Enlarged (myxedema,
mouth acromegaly, down
- Dorsum should be syndrome)
pink - Glossitis (red and
- The lateral aspect is smooth with absence
pink and smooth of papillae)
- Aphthous ulcer
(painful, round white
ulcerated lesion with
erythematous
boarders)
10.) Test for the - Tell the client to stick - The client should not - It cannot move
motor nerve function out his/her tongue have difficulties or smoothly and it is
of CN XII (Hypoglossal and instruct to move pain on moving painful when moving
Nerve) the tongue sideways his/her tongue - It cannot resist the
and up and down. - It can resist the force force exerted while
Also instruct the client exerted while pushing pushing
 Assessment of The Mouth

to push his/her tongue

on his/her buccal
mucosa and push your
hand against it.
11.) Test for the - Instruct the patient to - The patient was able - The patient wasn’t
sensory nerve function close his/her eyes and to distinguish the able to distinguish the
of CN VII (Facial stick his/her tongue taste taste
Nerve) and put some sugar or
salt
12.) Palpate the lips - Put clean gloves then - There should be no - There is tenderness
use a gauze pad to tenderness when when palpating
palpate the lips palpating
13.) Palpate the - Put a clean gloves the - There is no tenderness - There is tenderness
tongue instruct the patient to when palpating when palpating
stick out his/her - It is flabby (soft,
tongue and start loose, and fleshy)
palpating using a
gauze