Oral Cavity Assessment

Oral Cavity Assessment

History

• Last dental exam
• Missing, broken, or loose teeth
• Pain in the mouth, teeth, gums
• Bleeding gums
• Dry mouth
  • Sores or lesions in mouth/tongue
  • Difficulty biting, chewing, swallowing
• Presence of halitosis
• Altered sense of taste
• Dentures/partials
• Sores under dentures
• Stability during chewing
• History of head or neck radiation
• Usual dental/oral hygiene
• Medications

Assessment

Lips and Mouth

• Cracking, lesions, ulcers, swelling, discoloration, redness

Buccal Mucosa

• Induration, tenderness, abrasions, redness/discoloration, hydration, hygiene

Tongue

• Color, size, coating, tremor, lesions, deviation

Palate

• Symmetry, lesions, discoloration

Oropharynx

• Gag reflex, uvula position, masses, exudate, color, lesions

Gingiva

• Color, bleeding, edema, exudates, hypertrophy, recession from teeth, food impaction

Teeth

• Caries, root exposure, visible decay, missing or loose teeth, mobile and/or worn teeth

Black & Matassarin-Jacobs (1997); Forciea & Lavizzo-Mourey (1996); Jarvis (1992); Weber & Kelly (1998).

Source : http://nursing-assessment.blogspot.com

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