Assessment of The Mouth
Procedure How to perform
1.) Assess the smell of - You should stand at
the breath of the least 12 inches away
patient. from your client while
smelling the breath.
2.) Inspect the lips for: - When inspecting you
COLOR, MOISTURE, should stand at least
INTEGRITY, and 12 inches away from
SWELLING the client.
3.) Inspect the oral cavity - Ask the client to open
(gums, buccal his/her mouth and
mucosa, hard and soft inspect using a tongue
palate) depressor and a
penlight.
Normal Abnormal
- Breath should smell - Smells like ammonia;
fresh. usually associated
with kidney disease.
- Acetone breath; this
can be a sign of
diabetes.
- Halitosis or bad breath
- It should be PINK in - Presence of angular
color cheilosis; dryness on
- It should be MOIST the sides of the lips.
- There is no presence - Presence of lesions
of lesions - Inflamed/swollen
- There are no - Pale in color
inflammations - Cyanotic
- There are cracks
- For the gums: - For the gums:
• No swelling • Gingivitis (tender,
• No bleeding red, swollen and bleed
• Gum margins is well easily)
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
4.) Inspect the teeth for: - Ask the client to open
(number, color, his/her mouth and
alignment, presence inspect using a tongue
of dental appliances, depressor and a
and decay) penlight.
5.) Inspect the uvula - Ask the client to open
his/her mouth and
inspect using a tongue
depressor and a
penlight.
6.) Test for the motor - Instruct the patient to
nerve function of CN say “AHHHHHH” for
IX and X CN IX. Ask the patient
(Glossopharyngeal to swallow for CN X.
and Vagus nerve) Then use a penlight to
inspect.
7.) Check for the gag - Using a tongue
- 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)
- 32 teeth are present - Missing or absent
- White to yellowish teeth
color - Presence of dental
- Has smooth edges carries or tooth decay
- Properly aligned - Presence of dead
- There should be no tooth
decay or carries
- It is in the midline - Presence of lesions
- There is no swelling - Presence of exudates
- There is no exudate - Color is pale
- There are no lesions - Inflamed/swollen
- It should be pink in
color
- For the CN IX - For the CN IX
(Glossopharyngeal (Glossopharyngeal
nerve): nerve):
• The uvula should be • The uvula isn’t able
able to rise and fall to rise and fall
- For the CN X (Vagus - For the CN X (Vagus
nerve): nerve):
• Swallows easily • Painful and has
difficulties when
swallowing
- There should be a gag - There is no gag reflex
 Assessment of The Mouth
reflex depressor gently
stroke the posterior
part of the mouth
8.) Inspect the tonsils for: - Instruct the patient to
(color, grade, open his/her mouth
presence of exudates) and inspect using a
penlight
9.) Inspect the tongue - Instruct the patient to
for: (Symmetry, open his/her mouth
position, and presence and inspect using a
of lesions) penlight
10.) Test for the - Tell the client to stick
motor nerve function out his/her tongue
of CN XII (Hypoglossal and instruct to move
Nerve) the tongue sideways
and up and down.
Also instruct the client
reflex
- Tonsils should be pink
- It should be grade 1+
or 2+
- There should be no
exudates
- It is symmetrical
- It is moist
- It should be rough
- There are no lesions
- It should be located at
the midline of the
mouth
- Dorsum should be
pink
- The lateral aspect is
pink and smooth
- The client should not
have difficulties or
pain on moving
his/her tongue
- It can resist the force
exerted while pushing
- There is an exudate
- It is swollen
- There is a viral
pharyngitis and
tonsillitis (posterior
pharynx is red and
with white patches.
Tonsils are larger and
red with white
patches)
- The tonsils are grade
3+ or 4+
- The tongue is
deviated
- Candidiasis (a thick,
white curd-like coating
on tongue)
- Enlarged (myxedema,
acromegaly, down
syndrome)
- Glossitis (red and
smooth with absence
of papillae)
- Aphthous ulcer
(painful, round white
ulcerated lesion with
erythematous
boarders)
- It cannot move
smoothly and it is
painful when moving
- It cannot resist the
force exerted while
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