رابعة حديث 2 2- Examination of the Buccal mucosa

 Morphological features:-  It is the examination of the interior surface of the .  Color is light pink.  On the buccal mucosa near the 2nd maxillary molar is the parotid papilla, containing the opening of Stensen’s duct from the .  Linea alba buccalis it is a white line is seen corresponding to the line of occlusion of the teeth due to the force of the buccinator muscle pressing the mucosa over the teeth.  At the anterior termination of the linea alba there is a small, palpable nodule termed the Caliculus angularis.  The lateral labial frenum attaches the buccal mucosa to both the maxilla and the mandible at the level of the premolar teeth.  Fordyce’s granules and leukodema are considered to be variations of the normal topographic anatomy of buccal mucosa.

 Buccal mucosa can be examined by inspection and palpation. 1- inspection:-  The patient is instructed to open his mouth less than maximal opening and then retracting the cheek away from the teeth with a mirror or finger and inspect.  The mucosa should be dried with a gauze sponge and viewed again. 2- palpation of the cheek:-  It is performed bidigitally or bimanually to determine the consistency and pliability of the tissues, or deeply seated lesions.  The cheek is supported from outside by the four fingers of one hand and the thumb of the same hand or the index finger of the other hand runs in the inside of the cheek in different directions.  The firmness and indurations of the cheek may be found in cases of leukoplakia, submucous fibrosis and scleroderma. Common lesions of the cheek:- 1- White lesions:- Frictional keratosis, smoker keratosis, aspirin burn, candidiasis, leukoplakia, lichen plannus, lupus erythematosis … etc. 2- Pigmented lesions:- fordyce’s granules, racial pigmentation, amalgam tatto, petechia and ecchymosis. 3- Ulcerations:- traumatic ulcers, recurrent minor aphthous ulcerations, intraoral herpes and ulcers of herpes zoster. 4- Elevated lesions:- mucocele and papillomas.

Frictional keratosis and smokers keratosis Aspirin burn and candida Leukoplakia and lichen planus fordyce’s granules, racial pigmintation andpetechia and echymoisis Aphthous , herpes and truamatic ulcers mucocele and papillomas

3- Examination of the mucobuccal fold (buccal vestibule)

 Examined by inspection and palpation.  The patient is instructed to open his mouth.  Then retract the with fingers.  Asking the patient to bring the teeth nearly together.  The mucobuccal fold will be elevated almost to the height of alveolar ridge.  Palpation is performed by sliding the tip and bulb of the index finger along the alveolar surfaces at the periapical level to identify the tenderness or enlargement of periapical inflammatory lesions.  Features obtained by examination of the mucobuccal fold:- 1- Extent of the buccal and labial vestibules. 2- Symmetric contours. 3- Atypical elevations and depressions in bone. 4- Bony exostoses that interferes with insertion of dentures.

4- Examination of the hard

 Topographic anatomy:-  The palate is divided into 2 halves by the median .  Each half is divided into anterior and posterior quadrants.  The anterior quadrant contains fatty tissues in the submucous layer.  The posterior quadrant contains glandular structures (salivary glands) in the submucous layer.  Incisive papilla in the midline posterior to the maxillary incisor teeth.  The palatine raphe extends from the incisive papilla to just anterior to the uvula.  The palatine rugae runs transversely on either side it is important in speech particularly s letter.  Posterior part of contains many openings of accessory salivary glands.  The junction between soft and hard palate is called the vibrating (ah line).  A common bony hard enlargement at the midline called maxillary torus.

 Just anterior to the vibrating line and on either side of the palatine raphe there are two small depressions called the fovea palatina represent the openings of the palatine glands.  The posterior portion of the hard palate extends laterally to the area just distal to the last maxillary molar teeth and the rounded maxillary tuberosity.

 The hard palate examined by inspection and palpation. 1- inspection:-  Using direct and indirect light, the palate can be visualized directly and indirectly.  The color, contour, palatal height, rugae area, incisive papillae and width of the arch must be inspected.  Direct vision is performed from the sub-mental perspective with the patient head is hyperextended and the mouth is opened wide. This approach provides better visualization.  Indirect vision performed by mirror.  2- palpation of the palate:-  Performed by one finger starting from anterior region proceeding laterally up to the periapical level.  The junction between soft and hard palate should be palpated gently.  Any abnormal sensation such as eggshell cracking or fluctuation should be recorded.

Common lesions of the hard palate:- Pizza burn. Cleft palate. Minor tumors. Draining sinus from periapical abscess. Cysts. Pizza burn Cleft palate Draining sinus from periapical abscess. cysts

5- Examination of the and uvula

 Soft palate separates the mouth from the nose.  Its submucosal tissues is vascular so it appear more redder than hard palate but in older individuals it appears somewhat yellow due to increased proportion of submucosal fat accumulation.  It is movable during saying ah (elevation) or if the patient is instructed to blow air through the nose while the nostrils are compressed (depression).  Palpation of soft palate causes gaging sensation  Soft palate and uvula are examined by mouth mirror and reflected light as well as by depressing the .

Common lesions of the soft palate:-  Herpetic lesions (H.S, H.Z, herpangina)  Recurrent aphthous ulcers.  Petechia and ecchymoses.  Diphtheria. 6- Examination of the oropharynx:-  The anterior part of the lateral wall of the oropharynx are called the tonsillar fossae.  The tonsillar fossae are bounded anteriorly by the anterior pillar of which is formed by the palatogloss muscle.  The posterior pillar of fauces is formed by the palatopharyngeal muscle.  The space between the two pillars contains the .  The oropharynx is bounded postoriorly by the posterior pharyngeal wall and superiorly by the posterior border of the soft palate.  oropharynx is examined by direct and indirect inspection. Significance of examination:- 1- enlargements of pharyngeal and palatine tonsils causes mouth breathing by blocking the nasopharynx. 2- enlargements of the pharyngeal tonsils give rise to an acquired swallowing reflex, causing undesirable thrusting of tongue. 3- infected or inflamed tonsils may cause referred pain to the oral cavity

7- examination of the floor of the mouth

 Topographic anatomy:- 1- The lingual frenum divides the floor of the mouth into halves. 2- The sublingual caruncles are seen as two small projections on either side of the frenum and are often attached to the frenum. 3- Caruncles are the sites of the openings of wharton’s duct from the right and left submandibular salivary glands.  From the caruncles the sublingual folds seen as elevations running posteriorly, contains the sublingual salivary glands and their ducts (Bartholin’s and Rivinus ducts).  The area between the floor of the mouth and the skin covering the submandibular region of the neck contains the sublingual and submandibular salivary glands, the mylohyoid muscle, lymph nodes.

 Floor of the mouth examined by inspection and palpation.

1- inspection of the floor of the mouth:-  The floor of the mouth can be seen by having the patient lift the tongue to the roof of the mouth.  Using mirror light can be reflected onto the anterior portion of the floor.  The function of the submandibular salivary glands can be assessed by drying the caruncles and pressing the gland and watch the opening of the ducts.  The posterior floor and the lingual lateral border of the alveolar ridges can be examined by retracting the lateral border of the tongue with a mirror 2- palpation of the floor of the mouth:-  Performed by bimanual palpation, by fixing the tissues extraorally by the four fingers of one hand while the thumb is resting over the body of the mandible or by placing the index and middle fingers of one hand in the mouth and the fingertips of the opposing hand in the submandibular area.  The tongue should be relaxed and the patient mouth is slightly closed to make the structures more palpable.

 Common lesions in the floor of the mouth:-  Enlarged submandibular or submental lymph nodes.  Salivary stones along the course of wharton’s duct.  Nodular enlargement of the salivary gland.  Ranula and mucous retention cysts.  Dermoid and epidermoid carcinomas and cysts.

N.B. during examination of the floor of the mouth, the lingual contour of the mandible is examined visually and by palpation for:-  Atypical contour.  Mucosal lesions.  Periapical tenderness.  Bony exostoses.  Bilateral prominences of the lingual alveolar process in the canine region are called mandibular tori and are common findings