PHINMA-CAGAYAN DE ORO COLLEGE

Max Suniel St., Carmen Cagayan De Oro City

CAHS DEPARTMENT
S.Y. 2022-2023

PERFORMANCE CHECKLIST FOR ASSESSING

MOUTH AND OROPHARYNX
Definition:

Purpose(s):

Principle(s):

SCORES
STEPS RATIONALE REMARKS
5 4 3 2 1
Preparation:
1. Assemble equipment To keep equipment
and supplies: within reach and avoid
Examination gloves time consumption.
Tongue depressor
2x2 gauze pads
Flashlight or penlight
Procedure:
1. Explain to the client To enhance patient’s
what you are going to cooperation
do, why is it necessary,
and how he can
cooperate.
2. Wash hands and observe To prevent transfer of
other appropriate microorganism.
infection control
 procedures.
3. Provide for client To provide comfort and
privacy. safety
4. Determine client’s To determine that the
history of the following: current problem maybe
 Routine pattern recurrence of previous
of dental care one,
 Last visit to
dentist
 Length of time
ulcers or other
lesions have
been present
 Any denture
discomforts
 Any medications
client is
receiving
5. Position the client To ensures client
comfortably, seated if comfort.
possible.
Assessment:
LIPS AND BUCCAL MUCOSA
To identify deviations
from normal: pallor or
cyanosis of lips; blisters,
generalized or localized
swelling, fissures, crust,
6. Inspect the outer lips for
or scales (may result
symmetry of contour,
from excessive
color, and texture.
moisture, nutritional
Ask the client to purse
deficiency, or fluid
lips as if no whistle.
deficit); inability to
purse the lips may
indicate facial nerve
damage

To check for: pallor,

leukoplakia (white
7. Inspect and palpate the
patches), and bleeding;
inner lips and buccal
excessive dryness;
mucosa for color,
mucosal cyst, irritations
moisture, texture, and
from dentures;
the presence of lesions.
abrasions, ulceration;
nodules
TEETH AND GUMS
 The condition of the
teeth and gums is an
index of a person’s
general health. This
step will help to check
8. Inspect the teeth and for: missing teeth; ill-
gums while examining fitting dentures; brown
the inner lips and buccal or black discoloration of
mucosa. the enamel (may
indicate staining or
presence of caries);
excessively red gums;
receding and atrophied
gums
The condition of the
teeth and gums is an
index of a person’s
9. Inspect the gums around
general health. This
the molars. Observe for
step will help to check
bleeding, color,
for: missing teeth; ill-
retraction, edema and
fitting dentures; brown
lesions: • Assess the
or black discoloration of
texture of the gums by
the enamel (may
gently pressing the gum
indicate staining or
tissue with a tongue
presence of caries);
depressor
excessively red gums;
receding and atrophied
gums
10. Inspect the dentures. To check for: ill-fitting
Ask the client to remove dentures; irritated and
complete or partial excoriated areas under
dentures. Inspect their dentures.
condition, noting in
particular broken or
worn areas.
TONGUE/FLOOR OF THE
MOUTH
11. Inspect the surface of To check for: tongue
the tongue for position, deviation from the
color, and texture. center (may indicate
Ask the client to damage to hypoglossal
protrude the tongue. nerve); excessively
trembling tongue;
smooth red tongue
(may indicate iron,
vitamin B12 or B3
deficiency); dry furry
 tongue (associated with
fluid deficit); white
coating (may indicate
oral yeast infection);
nodes, ulceration,
discoloration; areas of
tenderness.
12. Inspect tongue To check for restricted
movement. mobility of the tongue
Ask the client to roll the (may indicate damage
tongue upward and to hypoglossal nerve
move it from side to
side.
13. Inspect the base of the
tongue, the mouth floor,
and the frenulum.
Ask the client to place
the tip of his tongue
against the roof of the
mouth.
14. Palpate the tongue and
floor of the mouth for
any nodules, lumps, or
excoriated areas.
Use a piece of gauze to
grasp the tip of the
tongue and, with the
index finger of your
other hand, palpate the
back of the tongue, its
borders, and its base.
SALIVARY GLANDS
15. Inspect salivary duct
openings for any
swelling or redness.
PALATES AND UVULA
16. Inspect the hard and soft
palate for color, shape,
texture, and the
presence of bony
prominences.
Ask the client to open his
mouth wide and tilt his
head backward. Then,
depress tongue with a
tongue blade as
 necessary, and use a
penlight for appropriate
visualization.
17. Inspect the uvula for
position and mobility
while examining the
palates.
To observe the uvula,
ask the client to say “ah”
so that the soft palate
rises.
OROPHARYNX AND TOSILS
18. Inspect the oropharynx To check for the
for color and texture. presence of lesions,
Inspect one side at a plaques, or drainage
time to avoid eliciting
the gag reflex. To
expose one side of the
oropharynx, press a
tongue blade against
the tongue on the same
side about halfway back
while the client tilts his
head back and opens
the mouth wide. Use a
penlight for illumination,
if needed.
To check for discharges,
inflammation or
swelling:
• Grade 1 (normal):
The tonsils are behind
the tonsillar pillars.
19. Inspect the tonsils for • Grade 2: The tonsils
color, discharge, and are between the pillars
size. and uvula.
• Grade 3: The tonsils
touch the uvula.
• Grade 4: One or both
tonsils extend to the
midline of the
oropharynx.
20. Elicit the gag reflex by
pressing the posterior
tongue with a tongue
depressor.
21. Document findings in To organize findings.
 the client record.
TOTAL:

Name of the Student:

Section:

Name of Clinical Instructor:

Date: