Expansion
Lips, mucosa, tongue, teeth, palate and tonsils, with a good light
Expansion
Sequence, with a pen torch, tongue depressor and gloves, dentures removed
- Lips: angular stomatitis (iron, B12, folate deficiency), herpes labialis, cyanosis, telangiectasia (hereditary haemorrhagic telangiectasia), pigmentation (Peutz-Jeghers)
- Buccal mucosa: candidiasis (white plaques that scrape off), lichen planus (Wickham’s striae, which do not), aphthous ulcers, Koplik’s spots, pigmentation (Addison’s disease), the parotid duct opposite the second upper molar
- Tongue: size, coating, glossitis (smooth and beefy, from B12, folate or iron deficiency), geographic tongue, ulcers, and the lateral borders and underside, where malignancy hides
- Teeth and gums: caries, gingivitis, gum hypertrophy (phenytoin, ciclosporin, nifedipine, leukaemia), gingival bleeding
- Hard and soft palate: petechiae, Kaposi’s sarcoma, cleft, palatal movement on saying “aah”, with the uvula deviating away from a vagal lesion
- Tonsils and oropharynx: size, exudate, asymmetry, and the posterior wall
- Neck nodes, always
Red flags for oral malignancy: a non-healing ulcer over three weeks, an indurated lesion, leukoplakia or erythroplakia, unexplained neck node, loose teeth, and the risk factors of smoking, alcohol, betel and human papillomavirus.
Quinsy (peritonsillar abscess) gives unilateral swelling with uvular deviation to the opposite side, trismus and a hot potato voice, and needs drainage.
Do not use a tongue depressor in a child with suspected epiglottitis or croup.