Which assessment finding would the nurse observe in a patient who has aphthous ulcers

Smooth Tongue

The most common cause of a smooth tongue is the use of dentures. Nutritional deficiencies include iron, folate and vitamin B12 deficiency. B12 deficiency will also make the tongue sore and beefy-red in color. Glossitis, by causing swelling of the tongue, may also cause the tongue to appear smooth. Among women, low-estrogen states may cause a “menopausal glossitis”.

A classic smooth, beefy red tongue from vitamin B12 deficiency (Credit)

Geographic Tongue

Geographic tongue is a benign condition in which discolored, painless patches of the tongue appear and then reappear from atrophy, often in a different distribution. This is seen in 1-3% of the population.

Geographic Tongue (Credit)

Hairy Tongue

White hairs along the sides of the tongue are the classic appearance of oral hairy leukoplakia, the result of EBV infection in HIV-positive individuals. A black hairy tongue in the setting of chronic administration of penicillins is often fungal overgrowth, particularly of aspergillus.

Oral Hairy Leukoplakia, in an HIV-positive individual. (Credit)

A black, hairy tongue consistent with aspergillus overgrowth (Credit)

Furrowing

Transverse furrows across the tongue may be from a benign condition called scrotal tongue. Furrows that are longitudinal along the length of the tongue are the result of syphilis.

Ulcers

In inspecting ulcers, it is important to note their size, number, color, distribution, and whether or not they cause the patient any discomfort.

Aphthous ulcers, or aphthous stomatitis, are a painful form of ulcer that is frequently encountered. It appears in one of several patterns: minor, major, or herpetiform. Minor aphthous ulcers are usually 2-8mm in size and spontaneously heal within 14 days. Major aphthous ulcers are >1cm in size and may scar when they heal. Herpetiform ulcers are pin-point size, often multiple, and may coalesce to form a larger ulcer. All may result in odynophagia when they occur toward the posterior surface of the oropharynx.

Recurrent aphthous ulceration or stomatitis (RAU/RAS) occurs in some systemic illnesses. These include Crohn's Disease and Ulcerative Colitis, Behcet's Syndrome, pemphigus, herpes simplex, histoplasmosis, and reactive arthritis (Reiter's Syndrome). Other causes of RAU include drug reactions, Marshall Syndrome, and MAGIC (Mouth and Genital ulcers with Inflamed Cartilage) syndrome. The ulcers themselves may become infected, requiring treatment.

A single non-healing, erythematous, painful ulcer suggests lingual or oral cancer, particularly if the patient uses tobacco and/or alcohol. Patient history and risk factors are important to note.

Micro/Macroglossia

Microglossia may result from pseudobulbar palsy, damage to the upper motor neurons of the corticobulbar tracts that innervate the tongue. This presents with a small, stiff tongue. In newborns there may be an apparent microglossia resulting from a congenitally short lingual frenulum (ankyloglossia) commonly called a “tongue tie”.

Assessment of macroglossia should include palpation of the sublingual glands; these will be displaced in true macroglossia. Macroglossia may be congenitally present in individuals with acromegaly. New-onset macroglossia in an adult is pathognomonic for amyloidosis and should be treated as such until proven otherwise.

Fasciculations

Fasciculations of the tongue are indicative of lower motor neuron injury. These may present with dysarthria or dysphagia. New-onset fasciculations are concerning for amyotrophic lateral sclerosis.

A mouth assessment is performed as part of a patient's health assessment. The mouth is the beginning of the digestive system and a substantial part of the respiratory tract. Before an assessment of the mouth, patient is sometimes advised to remove any dentures. The assessment begins with a dental-health questionnaire, including questions about toothache, hoarseness, dysphagia(difficulty swallowing), altered taste or a frequent sore throat, current and previous tobacco use and alcohol consumption and any sores, lesions or bleeding of the gums.[1]

Lips[edit]

The lips are normally symmetrical, pink, smooth, and moist. There should be no growths, lumps, or discoloration of the tissue. Abnormal findings are asymmetricality, cyanosis, a cherry-red or pale color or dryness. Diseases include mucocele, aphthous ulcer, angular stomatitis, carcinoma, cleft lip, leukoplakia, herpes simplex and chelitis.

Teeth[edit]

Tooth condition indicates a person's general health.[2] Teeth should be clean with no decay, white with shiny enamel and smooth surfaces and edges. Adults should have a total of 32 teeth (16 teeth in each arch). By the age of 2+1⁄2, children have a total of 20 deciduous teeth (10 in each arch). Abnormal findings are missing, loose, broken and misaligned teeth. Diseases of the teeth include baby-bottle tooth decay, epulis, meth mouth and Hutchinson's teeth.

Gums[edit]

To assess the gums, a tongue depressor gently retracts the cheek to allow inspection of the upper and lower gums. They should appear symmetrical, moist and pinkish, with well-defined margins. Dark-skinned people may have a melanotic line along the gum margin. Abnormal findings include swelling, cyanosis, paleness, dryness, sponginess, bleeding or discoloration. Diseases include leukoplakia, epulis, gingival hyperplasia, gingivitis, periodontitis and aphthous ulcer (canker sore).

Oral mucosa[edit]

To check the oral mucosa, the patient's cheek is exposed with a tongue depressor and the tissues inspected with a penlight. Healthy tissue appears moist, smooth, shiny and pink. Stensen's duct is opposite the second molar. Abnormal findings include dryness, cyanosis, paleness and Fordyce spots, and signs of disease include canker sores, Koplik's spots (an early indication of measles), candidiasis and leukoplakia.

Hard palate[edit]

The patient tilts their head back and opens their mouth for the hard-palate assessment. Visual inspection with a penlight shows a healthy palate as whitish in color, with a firm texture and irregular transverse rugae. Abnormal findings include yellowness or extreme pallor, and diseases include torus palatinus, cleft palate, submucous cleft palate, High-arched palate, Kaposi's sarcoma and leukoplakia.

Soft palate and uvula[edit]

The soft palate is checked with a penlight. It should be light pink, smooth and upwardly movable. To check the uvula, a tongue blade is pressed down on the patient's tongue and the patient is asked to say "ah"; the uvula should look like a pendant in the midline and rise along the soft palate. Abnormal findings include deviation of the uvula from the midline, an asymmetrical rise of the soft palate or uvula and redness of either. Diseases include bifid uvula, cleft palate and carcinoma. If cranial nerve 10 is injured, the soft palate does not rise when the mouth is opened.

Tongue[edit]

All sides of the tongue are assessed. To inspect the dorsal side (top) of the tongue, a patient sticks out their tongue. A healthy dorsal tongue is symmetrical, pink, moist, slightly rough from the papillae, possibly with a thin, whitish coating. The sides of the tongue are inspected with a gloved hand holding a piece of gauze. The tongue is moved side to side and inspected; it should be pink, moist, smooth and glistening. Assessment of the ventral (bottom) surface of the tongue is done by having the patient touch the tip of their tongue against the roof of their mouth. If healthy, it should have prominent veins and be pink, smooth, moist, glistening and free of lesions. The frenulum should be centered under the tongue. Abnormal findings includes marked redness, cyanosis or extreme pallor. Diseases include scrotal or fissured tongue, migratory glossitis (geographic tongue), atrophic glossitis, black hairy tongue, caviar lesions, carcinoma, macroglossia, candidiasis, aphthous ulcer and leukoplakia.

Tonsils (if present)[edit]

To assess the tonsils, a patient opens their mouth and a tongue blade is used to depress the tongue. A penlight is used to inspect the back of the patient's throat, looking for pink, symmetrical and normal-size tonsils. Tonsil size is graded as follows:

• 1+ Visible
• 2+ Halfway between the tonsillar pillars and the uvula
• 3+ Touching the uvula
• 4+ Touching each other

Abnormal findings include bright-red, enlarged tonsils or white or yellow tonsillar exudate. Tonsillitis is an inflammation of the tonsils.

Special populations[edit]

Patients with Down syndrome and cretinism have delayed tooth eruption, and prolonged thumb-sucking may cause problems with mouth growth and tooth alignment.[3] Gingivitis is one of the most prevalent oral problems associated with pregnancy, occurring in 60–75 percent of pregnant women.[4]

References[edit]

1. ^ "BPG Oral Health ENG - Oral Health Nursing Assessments and Interventions" (PDF). BPG Oral Health ENG. Retrieved 2015-07-15.
2. ^ Jarvis, Carolyn (2008). Physical Examination & Health Assessment. 5th edition. ISBN 978-1-4160-3243-4.
3. ^ "Archived copy" (PDF). Archived from the original (PDF) on 2008-12-03. Retrieved 2009-11-01.{{cite web}}: CS1 maint: archived copy as title (link)
4. ^ "Archived copy" (PDF). Archived from the original (PDF) on 2009-02-06. Retrieved 2009-11-01.{{cite web}}: CS1 maint: archived copy as title (link)

External links[edit]

• Tooth eruption chart

What is a normal finding during physical assessment of the mouth quizlet?

Which findings would be considered normal for a patients teeth?

Which findings would be causes of concern to the nurse while examining a patient's gums?

What findings would the nurse expect when inspecting the nasal mucosa of an individual with rhinitis?