Clinical Evaluation and

A n a t o m i c Var i a t i o n of t h e
Oral Cavity
Sunday O. Akintoye, BDS, DDS, MSa,*, Mel Mupparapu, DMD, MDSb

KEYWORDS

Oral cavity
Mucosa
Lip
Tongue
Exostosis
Lymphoid
Leukodema
Fordyce granules

KEY POINTS

Clinical evaluation of the oral cavity should include a thorough assessment of the soft and hard
tissues.

Distinguishing between normal and abnormal anatomic features in the oral cavity is vital to early
diagnosis of oral pathologic conditions.

Normal anatomic variations may mimic pathology.

Periodic observation or follow up may be needed for certain anatomic variations.

When symptomatic, these anatomic variations or abnormalities can be medically or surgically
treated to relieve the symptoms.

INTRODUCTION ANATOMY AND CLINICAL EVALUATION

TECHNIQUES
Evidence-based guidelines continue to point to Extraoral Region
a strong correlation between oral health and
systemic diseases,1,2 so health care providers Evaluation of the extraoral region starts with a vi-
should be knowledgeable regarding normal sual inspection to confirm the symmetric features
anatomy of the oral cavity and clinical implica- of the facial appearance and identify any obvious
tions of abnormal findings. Clinical evaluation deviation from normal. The right and left halves
of the oral cavity should start with the assess- of the face are usually mirror images of each other
ment of the head, face, and neck regions. It is so any asymmetry caused by disorder or facial
important to identify any asymmetry or changes palsy should be readily identified. Abnormal swell-
caused by abnormalities of the salivary glands, ings of the major salivary glands and lymph nodes
head and neck lymph nodes, and cranial nerves that may not be obvious during visual inspection
as well as changes in the skull size and shape. may be better appreciated by palpation of the right
In addition, any changes in skin color, and left sides of the head, face, and neck simulta-
abnormal pigmentation, and hairline distribution neously to compare both sides. The inspection of
could be an indication of pathologic conditions the neck should rule out any scarring, masses, or
that warrant further investigation. This article the presence of torticollis. Cervical lymphadenop-
presents an overview of anatomy, as well as athy can be ruled out by palpation of the lymph
anatomic variations often encountered during a nodes. Tracheal position should be inspected for
clinical evaluation. deviation from either a neck mass or more serious
conditions such as pneumothorax. The thyroid
derm.theclinics.com

a
Department of Oral Medicine, School of Dental Medicine, University of Pennsylvania, 240 South 40th Street
Suite 211, Philadelphia, PA 19104, USA; b Department of Oral Medicine, School of Dental Medicine, University
of Pennsylvania, 240 South 40th Street Suite 214, Philadelphia, PA 19104, USA
* Corresponding author.
E-mail address: akintoye@upenn.edu

Dermatol Clin 38 (2020) 399–411

https://doi.org/10.1016/j.det.2020.05.001
0733-8635/20/Ó 2020 Elsevier Inc. All rights reserved.
400 Akintoye & Mupparapu

gland should be inspected at both rest and as the

patient swallows for goiters or nodules. If posi-
tioned behind the patient, the thyroid gland can
be palpated for identification of the isthmus and
the lateral lobes, both at rest and as the patient
swallows, to be able to identify goiter, nodule, or
thyroiditis. Cranial nerve II to XII function should
be generally assessed. The presence of any
abnormal findings often indicates the need to crit-
ically evaluate for any associated or corroborating
intraoral abnormal features during the intraoral
evaluation.

Oral Region
The anatomic structures in the oral region of the Fig. 1. Oral cavity. The oral cavity showing the space
in the interior of the mouth between the upper and
head and neck include the lips, oral cavity proper,
lower dental arches with their respective maxillary
palate, tongue, floor of mouth, and oropharynx and mandibular teeth.
(Fig. 1). The mouth or oral cavity is the gateway
to the body through the gastrointestinal tract. It
consists of unique structures that perform many and the palatoglossal arches bordering the
functions essential for life. These functions include oropharynx on each side. Superiorly, the oral cav-
mastication, speech, respiration, digestion, swal- ity is separated from the nasal cavity by the hard
lowing, and taste. and soft palates. Inferiorly, the mylohyoid muscle
The processing and digestion of food start with extends from the left and right mandible to support
a well-functioning oral soft and hard tissues and the tongue and floor of the mouth. The terminol-
salivation.3,4 Poor nutrition heightens the chances ogies used to describe different areas of the oral
of poor oral health.5 Several aging changes and cavity are based on their relationship to the tongue
medication side effects that diminish appetite, within the oral cavity proper, the palate, cheek,
taste, and smell sensitivities, and oral mucosal facial surface, or lips, which all define the bound-
properties, can affect nutritional status and often aries of the oral cavity. Hence, the term lingual de-
become evident in the oral cavity.6 scribes a structure closest to the tongue, palatal
and buccal describe the ones closest to the palate
Oral cavity
or inner cheek respectively, and facial or labial are
The oral cavity consists of the vestibule and oral
used to describe structures closest to the facial
cavity proper. The vestibule is the space between
surface or lips, respectively.
the teeth and the mucosa of the lips and cheeks
(see Fig. 1). The vestibule is bounded medially
Lips and cheeks
by the teeth and its anterior and lateral boundaries
Visual inspection and palpation of the upper and
are the intraoral mucosal surfaces of the lips and
lower lips, the muscular folds that surround the
cheeks. The vestibule gradually narrows posteri-
entrance of the mouth, is important (Fig. 2). This
orly as the medial and lateral boundaries converge
inspection allows assessment of color changes,
at the retromolar region, which is the region of the
firmness, and presence or absence of any unusual
oral cavity posterior to the last mandibular and
maxillary molar teeth. However, the oral cavity
proper is the space in the interior of the mouth be-
tween the upper and lower dental arches occupied
by the tongue when the mouth is closed or at rest
(see Fig. 1). The teeth and alveolar bone on the left
and right sides separate the vestibule on each side
from the oral cavity proper. The oral cavity proper
is bounded anteriorly and laterally by the lingual
surfaces of the teeth and alveolar processes on
the left and right sides of the mouth (see Fig. 1).
The circumoral facial muscles control the opening Fig. 2. Upper and lower lips. The outline of the upper
of the mouth vestibule and the muscles of masti- and lower lips showing the distinct vermilion zone
cation control movement of the mandible. The and vermilion border where the skin of the external
posterior limit of the oral cavity is the oropharynx aspect of the lips terminates.
 Clinical Evaluation of the Oral Cavity 401

nodules. The skin of the external aspect of the lip

terminates at the vermilion border, which marks
the beginning of transition to the vermilion zone.
The darker appearance of the vermilion zone rela-
tive to the surrounding skin is caused by the un-
derlying blood vessels beneath the thin surface
epithelium. The vermilion zone gradually blends
intraorally with the oral mucosa (see Fig. 2). During
a visual inspection, it should be noted that the
width of both lips is usually within the distance be-
tween the irises of the eyes. The philtrum, a midline
vertical groove on the upper lip, extends from the
nasal septum to the tubercle region of the upper
lip, making it easy to identify asymmetry in a pa- Fig. 4. Evaluation of the buccal mucosa. Assessment
tient’s appearance. Palpation of the lips is best of the buccal mucosa and mucobuccal vestibular
achieved by pulling out each lip slightly and fold can be facilitated by using a wooden spatula or
palpating it bidigitally both extraorally and intraor- dental mouth mirror to retract the cheeks.
ally (Fig. 3).
on the left and right sides of the oral cavity as the
Oral mucosa mucobuccal fold to distinguish where the buccal
The oral cavity mucous membrane, referred to as mucosa reflects onto the alveolar bone, which
mucosa, is named and identified based on its loca- supports the posterior teeth. The mucous
tion within the oral cavity. On histology, the oral membrane that covers the alveolar bone, in which
mucosa is made up of stratified squamous epithe- the roots of the teeth are anchored, is referred to
lium that may or may not be keratinized, depend- as alveolar mucosa. To thoroughly examine the
ing on the region of the oral cavity. The labial buccal mucosa, the patient should be asked
mucosa lines the inner portions of the lip, whereas to open the mouth slightly and the lips and
the buccal mucosa lines the inner portion of the cheeks pulled away gently from the teeth with a
cheeks (see Fig. 3; Fig. 4). Intraorally, the labial wooden spatula or dental mouth mirror if available
mucosa terminates at the vestibular fold as it (see Figs. 3 and 4). Bidigital palpation and circum-
gradually reflects onto the alveolar bone support- ferential compression with 1 finger on the cheek
ing the anterior teeth. The anterior vestibular fold, extraorally and another finger intraorally on the
known as the mucolabial fold, extends posteriorly buccal mucosa makes it easy to identify any
mass within the soft tissues.

Gingivae
The oral mucosa terminates around the teeth as
gingiva that surrounds the maxillary and mandib-
ular teeth (Fig. 5). The nonattached, scallop-
shaped marginal gingiva covers the roots of teeth
anchored within the alveolar bone. The marginal

Fig. 5. Gingiva. The gingiva is separated into the

scallop-shaped nonattached marginal gingiva and
the attached gingiva tightly adherent to the alveolar
Fig. 3. Evaluation of the lips. Assessment of the lips is bone. The mucogingival junction demarcates the
best achieved by pulling each lip slightly to palpate its transition zone between the attached gingiva and
extraoral and intraoral surfaces. alveolar mucosa.
402 Akintoye & Mupparapu

gingiva wedged between adjacent teeth is the

interdental gingiva or papillae. The inner surface
of the marginal gingiva that juxtaposes the tooth
surface harbors a space called the sulcus or
crevice filled with saliva, known as crevicular fluid.
The marginal gingiva extends as the firm attached
gingiva that is tightly adherent to the alveolar bone
surrounding the roots of the teeth (see Fig. 5).
Often the attached gingiva has regions of pigmen-
tation that are dictated by race or ethnicity. It is Fig. 6. Palate. The hard palate showing distinct paral-
common for African people and dark-skinned indi- lel transverse mucosal ridges or rugae.
viduals to have attached gingiva that is darker than
the surrounding oral mucosa. This condition
two-thirds, or the body of the tongue, which re-
should be distinguished from so-called beauty tat-
sides in the oral cavity and is readily visible when
toos, which are common in some ethnic groups,
protruded (Fig. 8A). The posterior third of the
and amalgam tattoo, which can occur because
tongue, or base of the tongue, is less mobile
of inadvertent impregnation of amalgam particles
because is attached to the floor of the mouth
into the gingiva during a dental procedure. The
and extends down into the pharynx. Most of the
demarcation between the attached gingiva and
tongue base is usually not visible during a routine
the loose, slightly more movable alveolar mucosa
examination. The ventral surface of the tongue is
is the mucogingival junction.
in contact with the floor of the mouth, whereas
the top or dorsal surface is covered with many
Palate
lingual papillae (see Fig. 8A). A midline median sul-
A visual examination of the palate reveals that the
cus on the dorsum of the tongue runs posteriorly
palatal mucosa extends laterally on the left and
from the apex or tip of the tongue. It bisects the
right to the palatal gingiva overlying the maxillary
tongue into 2 equal halves so, during a clinical
arch in the oral cavity. The mucosa of the anterior
evaluation, it is possible to identify any asymmetry
hard palate is dense, firmly attached to the under-
and the location of any variations, abnormality, or
lying palatal bone, and has distinct parallel trans-
lesions caused by a disorder. The dorsum of the
verse mucosal ridges or palatal rugae (Fig. 6).
tongue has slender, threadlike filiform lingual
The median palatal raphe is a midline ridge of tis-
papillae that can be readily differentiated from
sue that bisects the hard palate into 2 equal left
the red mushroom-shaped fungiform lingual
and right regions. The soft palate occupies the
papillae. The tongue should be carefully examined
posterior third of the palate. It has a smooth and
by grasping and pulling it forward with a piece of
movable mucosa because it does not have any
gauze pad wrapped around the anterior third to
bone support like the hard palate. Its posterior
get a firm grip (Fig. 8B). Further posteriorly, an
free edge ends in a midline pendulous projection
inverted V-shaped groove with the tip pointing
called the uvula (Fig. 7). On either side of the uvula
posteriorly toward the pharynx, called sulcus
are the anterior and posterior arches forming the
palatoglossus and palatopharyngeal arches. The
palatal tonsils, a mass of lymphoid tissue, is posi-
tioned between the 2 arches. The hard and soft
palates can be readily palpated but it is advisable
to visually inspect the uvula to avoid causing a gag
reflex. This inspection can be achieved by gently
depressing the tongue with a wooden tongue
depressor while asking the patient to say “Ah” to
observe a slight anteroposterior movement of the
uvula and a more conspicuous view of the pharyn-
geal arches.

Tongue
When describing the tongue, the terms dorsal and Fig. 7. Soft palate and uvula. The soft palate showing
ventral are not synonymous with posterior and the uvula at the midline of the posterior edge. On
anterior respectively because all are descriptive either side of the uvula are the anterior and posterior
terms that separately apply to the tongue. The arches forming the palatoglossus and palatopharyng-
bulk of the tongue is the highly mobile anterior eal arches.
 Clinical Evaluation of the Oral Cavity 403

Fig. 8. Dorsal (A) and ventral (B) tongue and grasping of tongue with gauze. The tongue is best assessed by
grasping and pulling it forward with a piece of gauze pad wrapped around the anterior third to get a firm grip.

terminalis, is visible at the intersection of the ante- the lateral borders of the tongue. They are located
rior two-thirds and posterior third of the tongue. anterior to the circumvallate papillae. The foliate
Lining the anterior side of the sulcus terminalis lingual papillae are vestigial in humans and should
are the larger mushroom-shaped circumvallate not be confused with an abnormal tongue lesion.
lingual papillae (Fig. 9). Note that the tip of the Foliate lingual papillae appear brighter red than
inverted V pattern has a small, pitlike depression the surrounding lingual mucosa, and contain taste
known as foramen cecum. If the tongue is pulled buds and lymphoid tissues. Lingual tonsils can
further forward, the irregular mass of tonsillar tis- become enlarged if traumatized or during upper
sue, the lingual tonsil, will be visible. This mass is respiratory tract infections. The corresponding
different from the palatine tonsils on either side
of the uvula between the palatoglossus and pala-
topharyngeal arches. Foliate lingual papillae are
bilaterally symmetric areas of pinkish-red vertical
folds or grooves located in the posterior part of

Fig. 10. Ventral tongue. Black arrows point to the

prominent lingual nerves bilaterally on the ventral
Fig. 9. Circumvallate lingual papillae. Black arrow- surface of the tongue, and the black arrowhead
heads point to the mushroom-shaped circumvallate points to the sublingual caruncle through which the
lingual papillae and the black stars indicate the exces- submandibular and sublingual salivary glands secrete
sive coating on the dorsum of the tongue. saliva into the floor of the mouth.
404 Akintoye & Mupparapu

enlargement of the foliate papillae is referred to as ventral surface of the tongue, bisecting the floor of
transient lingual papillitis.7,8 Both foliate papillae the mouth and terminating on the lingual gingiva
and lingual tonsils are normal anatomic structures between the 2 mandibular central incisors. On
and no treatment is indicated for their enlargement either side of the lingual frenum are the sublingual
because the condition is transient. Although the caruncle, the papillae that contain the openings of
tongue is still gently pulled forward during an oral the ducts of the submandibular salivary glands.
evaluation, the lateral borders of the tongue should Also, conspicuously visible on the floor of the
also be examined for any mucosal or papillary mouth is a horseshoe-shaped swelling, the sublin-
changes. An evaluation of the tongue should gual fold or ridge caused by the underlying sublin-
conclude by asking the patient to raise the tongue gual salivary glands. The sublingual fold has
to inspect the ventral or sublingual surface multiple ductal openings of the sublingual salivary
(Fig. 10). The sublingual mucosa is thin, shiny, gland. Some of these ducts also merge with the
and transparent, disclosing numerous blood ves- submandibular salivary gland duct to secrete
sels, especially the 2 large, deep lingual veins saliva into the floor of the mouth at the sublingual
that run parallel on either side of the tongue caruncle (see Fig. 10). The floor of the mouth
midline. Lateral to each lingual vein are folds of should be assessed by bimanual palpation. This
fingerlike projections called plica fimbriata. palpation is done by placing the index finger of 1
hand intraorally in the floor of the mouth and 1 or
Lymphoid aggregates 2 fingertips of the opposite hand extraorally under
Lymphoid aggregates are typically collections of the chin (Fig. 11). By compressing the tissues be-
focal hyperplastic lymphoid tissue or normal tween the fingers, it is possible to compare the
lymphoid tissue that may occur anywhere in the right and left sides of the floor of the mouth and
oral cavity (see Fig. 7). They are commonly seen feel for any unusual nodule. If the sublingual
in the region of the Waldeyer tonsillar ring, which caruncle is carefully dried with a piece of gauze
includes the floor of the mouth, soft palate, lateral swab, the submandibular and sublingual salivary
border of the tongue, and oropharynx. Lymphoid glands can be compressed to observe salivary
tissue on the lateral wall of the oropharynx around flow from the ductal orifices.
the opening of the eustachian tube is referred to as
tubal tonsils. The combination of the palatine ton-
sils, lingual tonsils, and tubal tonsils complete the
Waldeyer tonsillar ring. Lymphoid tissue aggre-
gates within the mucosa of the roof of the naso-
pharynx are collectively referred to as the
pharyngeal tonsil. These aggregates are located
in the midline and form the superior aspect of the
Waldeyer tonsillar ring. The lymphoid aggregates,
when enlarged, are referred to as adenoids.

Floor of mouth
The floor of the mouth is inferior to the ventral sur-
face of the tongue. It is bounded by the mylohyoid
muscle inferiorly, the medial surface of the right
and left mandibular body, and superiorly by a
thin mucosal layer that is continuous with the mu-
cous membrane of the ventral tongue. Beneath the
thin mucosa of the floor of the mouth are several
blood vessels, nerves, ganglia, and 2 major sali-
vary glands on either side of the midline: the sub-
lingual and submandibular salivary glands. Also
note that the lingual nerve, which is the terminal
branch of the mandibular nerve, has a variable
course in its relationship to the mandibular alveolar
Fig. 11. Bimanual palpation of the floor of the
crest, submandibular salivary gland duct, and floor mouth. The anatomic structures in the floor of the
of the mouth. It innervates the mucous membrane mouth assessed by bimanual palpation. Note the in-
of the anterior two-thirds of the tongue, floor of oral dex finger of 1 hand intraorally in the floor of the
cavity, and the adjacent lingual gingiva. The lingual mouth and 1 or 2 fingertips of the opposite hand
frenum is a midline fold of tissue that runs from the placed extraorally under the chin.
 Clinical Evaluation of the Oral Cavity 405

Teeth that the amount of saliva in their mouth is enough,

It is more practicable to examine the teeth with the too little, or too much. This step is one of the first in
appropriate dental instruments, which include a identifying individuals with hyposalivation.
dental mouth mirror and dental explorer. However,
dental arches in which the teeth are anchored can
ANATOMIC VARIATIONS
be divided into 4 quadrants: right and left maxillary
Extraoral
and right and left mandibular quadrants (see
Fig. 1). Adults have a total of 32 teeth, so each Lip pits
quadrant with full complements of permanent Lip pits are developmental anomalies occurring
teeth should contain 2 incisors, 1 canine, 2 premo- commonly on the vermilion border of the lower
lars, and 3 molars. However, children before the lip, although they can also occur on the upper lip
age of 6 years have a total of 20 teeth and each and the commissures or angles of the mouth
quadrant of the dental arch with full complements (Fig. 12). The lip pits are also associated with a
of deciduous teeth should contain 2 incisors, 1 rare autosomal dominant syndrome called van
canine, and 2 molars. Several terms are applicable der Woude syndrome, where lip pits occur inde-
when describing each tooth. The crown is the pendently or in association with cleft lip/cleft pal-
exposed part of the tooth in the oral cavity, ate.9 The prevalence of van der Woude
whereas the root is the part anchored in the alve- syndrome ranges from 1 in 75,000 to 1 in
olar bone. The crown of each tooth has multiple 100,000 live births. Cleft lip with or without cleft
surfaces. The occlusal surface of the crown refers palate occurs in about 70% of patients with van
to the masticating or biting surface; the vestibular der Woude syndrome. Associated findings in this
surface of the crown, which faces the vestibule, is syndrome include hypodontia, club foot, syndac-
identified as the buccal surface if it is on a poste- tyly of hands, and genitourinary and cardiovascu-
rior tooth facing the cheek or the labial surface if lar abnormalities. Studies have identified
it is on an anterior tooth facing the lips. The lingual abnormal chromosome band 1q32-q41 and 1p34
surface faces the tongue, the mesial surface is the in patients affected with the van der Woude syn-
side of the crown closest to the patient’s midline, drome.10 The lower lip pits can occur bilaterally
whereas the distal surface is the side of the crown and can be shallow or deep depending on the de-
farthest from the midline. gree of gene expression. The pits sometimes con-
nect to the orbicularis oris muscle and, if deep
Salivary glands and saliva enough, can develop to a fistula. Occasionally,
A thorough clinical evaluation of the oral cavity the pits penetrate the minor and accessory sali-
should also include palpation of the major salivary vary glands located in the lips, resulting in salivary
glands. The ducts of the paired parotid glands secretion from the pits. Genetic evaluation and
located in the preauricular and infra-auricular re-
gions open intraorally in the buccal mucosa oppo-
site the second maxillary molar tooth. By gently
palpating and expressing the glands, flow of saliva
from the parotid glands can be assessed intraor-
ally by observing the secretions at the ductal
openings. Bimanual digital palpation is the best
way to “milk” the submandibular and sublingual
salivary glands while observing the salivary flow
from their ductal orifices at the floor of the mouth
(see Figs. 10 and 11). The quantity of saliva based
on flow and quality based on its organic and inor-
ganic components are essential for the multiple
functions of saliva.7 Individuals with reduced sali-
vary flow are susceptible to different oral disor-
ders. Hyposalivation or decreased salivary flow
can cause increase in oral microbial load, making
oral mucosa susceptible to candidal infections,
and the teeth are also at higher risks of developing
dental caries. Xerostomia is a complaint of dry
mouth caused by hyposalivation. Symptoms of Fig. 12. Bilateral commissural lip pits. Lip pits (arrows)
dry mouth vary from individual to individual, so pa- are common developmental anomalies that may occur
tients should always be asked whether they think in the vermilion border or the angles of the mouth.
406 Akintoye & Mupparapu

counseling are recommended for patients with Table 1

congenital lip pits and, if clinically indicated, surgi- Classification of lip prints
cal excision is the treatment of choice.9
Type A clear-cut line or groove
Venous lakes I & I0 running vertically across
Venous lakes are benign pigmentations caused by the lip, or straight grooves
dilated veins that are small. Typically seen in that disappear halfway
adults, these lesions are also known as phlebec- into the lip instead of
tases. They present as small, bluish-purple, covering the entire breadth
slightly elevated soft tissue lesions that are notice- of the lip or partial-length
able on the exposed skin. The most common groove of type I
occurrence is reported in the face, lips, and the he- Type II Grooves that fork in their
lix of the ears. The diagnosis of venous lakes is course, or a branched
almost exclusively by appearance. On pressing, groove
the color of the venous lake macule or papule dis- Type III An intersected groove
appears as the blood is cleared from the site. This Type IV A reticular groove
finding is pathognomonic of this condition. A glass Type V Grooves that are not in any
slide or the lens of a dermatoscope can be used to of the above categories
elicit this sign. and cannot be differentiated
morphologically
Sulci labiorum (lip prints)
Data from Andreeva VA, Kesse-Guyot E, Galan P, et al.
The pattern of wrinkles (lip prints) on the upper and
Adherence to National Dietary Guidelines in Association
lower lips is unique to each individual11,12 (Fig. 13). with Oral Health Impact on Quality of Life. Nutrients
Evaluation of lip prints relative to the surrounding 2018;10(5); and Solemdal K, Sandvik L, Willumsen T,
anatomy has been found to be stable and record- et al. The impact of oral health on taste ability in acutely
able, and classification of lip prints (Table 1) con- hospitalized elderly. PLoS One 2012;7(5):e36557.
tributes to the armamentaria used in forensic
sciences.13 are ectopic sebaceous glands trapped within the
skin or epithelium that occurs in more than 80%
Intraoral
of adults.14 Sebaceous glands are part of normal
Fordyce granules skin in association with hair follicles. However,
Fordyce granules are commonly noted variations they present intraorally as yellowish-white papular
of normal anatomy within the oral mucosa. They areas of about 1 to 2 mm in diameter scattered

Fig. 14. Fordyce granules. Black arrows point to

ectopic sebaceous glands trapped within the epithe-
Fig. 13. Individual variations of lip prints. The lium of the buccal mucosa presenting as Fordyce gran-
vermilion zone of the lips display distinct pattern of ules. Black arrowheads identify the linea alba buccalis
wrinkles or prints unique to each individual. on the buccal mucosa.
 Clinical Evaluation of the Oral Cavity 407

throughout the oral mucosa. They can be identified

in the buccal mucosa bilaterally (Fig. 14) and on
the vermilion of the upper lip. Fordyce granule
seem to become more visible in the oral cavity af-
ter puberty because of hormonal changes, and
their number is thought to increase with age.14
Fordyce granules are asymptomatic and treatment
is not necessary. On rare occasions if a biopsy is
performed on an unusual presenting sebaceous
gland, pseudocysts, sebaceous cell hyperplasia,
and adenomas have been reported after a bi-
opsy.15 Fordyce granules can also mimic the
appearance of pseudomembranous candidiasis,
but candida plaques can be easily removed, Fig. 15. Lingual varicosities. Black arrow points to the
whereas the Fordyce granules do not wipe off. prominent dilated lingual vein or varicosity of the
right side but obscured by a white lesion on the left
Lingual varicosities side shown by black arrowhead.
Varicosities are abnormally dilated veins that are
commonly seen in the elderly. Although they can
be seen on any location, the most common loca- molar regions along the buccal and palatal bony
tions are lips, buccal and labial mucosa, and shelves (torus maxillaris), which may extend to
ventral portion of the tongue (Fig. 15). It is thought the region of the maxillary tuberosity. They can
that the varicosities are formed because of weak- also be located bilaterally along the lingual cortical
ening of the vessel wall secondary to aging. plate of the mandible (torus mandibularis) (Fig. 16)
Because they are variations of normal anatomy, or isolated beneath the labial and buccal alveolar
no treatment is necessary except for esthetic rea- mucosa (exostoses).
sons. The lesions become thrombosed on occa- Because of the thin oral mucosa overlying the
sion.16 On sites such as the lips, the varicosities bony exostoses, tori appear as pale yellowish
may mimic mucoceles. white because of the color of the underlying
bone. Although these are distinct entities, clini-
Leukoedema cians must be careful to distinguish them from
Leukodema is a benign grayish-white appearance the bony expansions associated with other den-
and often involves the buccal mucosa. It is an inci- toalveolar disorders, such as fibrous dysplasia,
dental finding during intraoral examination. Leuko- cemento-osseous dysplasia, or Paget disease.
dema is characterized by the accumulation of fluid No treatment is necessary unless it is clinically
within the epithelial cells of buccal mucosa. It pre- indicated to perform surgical recontouring before
sents clinically as a white transparent mucosal prosthodontic treatment.
alteration located bilaterally in the buccal mucosa
with crisscrossing folds or lines within the area.14 It Benign migratory glossitis (geographic tongue)
is more common in men and less common in the Benign migratory glossitis, or erythema migrans, is
white population. A distinguishing feature of leuko- also commonly known as geographic tongue. This
dema is the clinical stretch test because it disap-
pears when the mucosa is stretched. The
differential diagnosis of this benign clinical entity
includes white spongy nevus, frictional keratosis,
Darier disease, pachyonychia congenita, candidi-
asis, lichen planus, and benign intraepithelial dys-
keratosis.17 There is no known relationship
between leukoedema and dysplasia, and no treat-
ment is necessary for leukodema because it is a
variation of normal anatomy.

Exostosis: maxillary and mandibular tori and

variations
Tori, also known as exostosis, are benign dense
cortical nodular osseous structures. They may be Fig. 16. Torus mandibularis. Bilateral exostosis or tori
located in the midline of the hard palate (torus on the lingual surface of the mandible (black arrows),
palatinus) or bilaterally in the posterior maxillary which are dense cortical nodular osseous swellings.
408 Akintoye & Mupparapu

condition is characterized by red, erythematous

regions of the dorsal and lateral borders of the
anterior two-thirds of the tongue. The prevalence
of geographic tongue is about 2% to 3% in the
general population.18 This condition features
well-demarcated red areas caused by atrophy of
the filiform papillae. The erythematous zones are
more conspicuous because they are either
partially or completely surrounded by a slightly
elevated white scalloped or serpentine border
(Fig. 17).14 During the healing phase, the periph-
eral zone is the first to disappear, followed by heal-
ing of the red zone.
On histology, geographic tongue is character-
ized by hyperkeratosis and acanthosis resembling
psoriasis. Therefore, some investigators consider
it to be a form of intraoral psoriasis.19 Geographic Fig. 18. Oral frictional keratosis. Hyperkeratosis of the
tongue is usually asymptomatic and no treatment buccal mucosa caused by trauma from habitual cheek
is required. Some patients complain of burning biting.
sensation or increased sensitivity to hot or spicy
foods. Topical steroids and or anesthetic agents
by the anterior teeth, and this is known as morsi-
along with reassurance is the treatment of choice.
catio labiorum. A biopsy and microscopic
assessment can be used to differentiate morsica-
Morsicatio buccarum (oral frictional tio from linea alba buccalis and white spongy
hyperkeratosis) nevus.
Morsicatio buccarum, or cheek biting, is often
noted in patient with compulsive neurosis
Linea alba buccalis
(Fig. 18). The patient bites off pieces of the buccal
Line alba buccalis is a whitish-gray horizontal line
mucous membrane, leading to excessive hyper-
on the buccal mucosa that is oriented parallel to
keratosis.20 The typical location of hyperkeratosis
the occlusal plane of the teeth (Fig. 19). It usually
in patients with morsicatio buccarum is along the
presents bilaterally in the oral cavity as a hyperker-
line of the occlusal plane of the teeth, signifying
atotic response to physiologic function, where the
the contact between upper and lower teeth. The
negative pressure pulls the buccal mucosa toward
mucobuccal folds are not affected by the trauma.
The inner lip may also be irritated and traumatized

Fig. 19. Prominent linea alba buccalis on the left

cheek mucosa. Whitish-gray hyperkeratotic horizontal
line (arrowheads) on the buccal mucosa oriented par-
allel to the occlusal plane of the teeth. This condition
Fig. 17. Geographic tongue. Patchy red, erythema- is caused by repetitive negative pressure that pulls
tous regions on the dorsal and lateral borders of the and attaches the buccal mucosa onto the buccal sur-
anterior two-thirds of the tongue characterize faces of the teeth leaving a keratotic line along the
geographic tongue. occlusal plane.
 Clinical Evaluation of the Oral Cavity 409

the teeth, causing a hyperkeratotic response. Linea

alba buccalis is present in the oral cavity in about
13% of population and needs no treatment.21

Common oral disorders

Ankyloglossia Ankyloglossia is a developmental
anomaly of the tongue characterized by an abnor-
mally short, thick lingual frenum resulting in limita-
tion of tongue movement. Complete ankyloglossia
occurs when a short lingual frenum extends to the
tip of the tongue causing restricted tongue move-
ment. Most cases of ankyloglossia are partial
ankyloglossia where the tip of the tongue has
movement and flexibility but the tongue itself has
some restricted movement (Fig. 20). Babies with
ankyloglossia have difficulty with suckling during
breastfeeding and adults may develop phonation
and speech difficulties.22
Hairy tongue (lingua villosa nigra) Hairy tongue, Fig. 21. Fissured or scrotal tongue. Dorsal surface of
sometimes also called black hairy tongue, is a the tongue displaying multiple small shallow and
benign condition characterized by elongation of deep grooves or fissures.
the filiform papillae with a typical carpetlike pre-
sentation on the dorsum of the tongue. Predispos- the condition is termed fissured tongue. The fis-
ing factors are smoking, excessive coffee or black sures can be single or multiple, shallow or deep,
tea consumption, poor oral hygiene, general debil- and occur commonly in the anterior two-thirds of
itation, xerostomia, and polypharmacy. Hairy the tongue (Fig. 21). Other terms used to describe
tongue can also appear brown, green, blue, or fissured tongue include scrotal tongue, plicated
nonpigmented. Black hairy tongue is generally tongue, and lingua plicata. The cause of fissured
asymptomatic but may be associated with hali- tongue is unknown. No treatment is necessary
tosis, metallic taste, dysgeusia, burning mouth, but the patient is encouraged to clean the surface
and gagging. of the tongue, preferably with a toothbrush, to pre-
Fissured tongue When the dorsal surface of vent food debris from getting trapped within the
tongue shows multiple small grooves or fissures,

Fig. 22. Lateral scalloped tongue or lateral crenations.

Tongue displaying scalloped or crenated margins
Fig. 20. Ankyloglossia. An abnormally short and thick often caused by pressure on an enlarged tongue by
lingual frenum restricting tongue movement. the surrounding teeth.
410 Akintoye & Mupparapu

fissures. This cleaning prevents halitosis, tissue perception, swallowing and initial digestion. Oral
irritation, and even inflammation.23 Dis 2018;24(8):1399–416.
4. Touger-Decker R, Mobley C, Academy of N, et al.
Crenations of tongue (scalloped Position of the Academy of Nutrition and Dietetics:
tongue) Crenated or scalloped tongue is a varia- oral health and nutrition. J Acad Nutr Diet 2013;
tion of normal tongue appearance caused by a 113(5):693–701.
combination of factors that include the size of 5. Andreeva VA, Kesse-Guyot E, Galan P, et al. Adher-
the tongue, size of the teeth, status of existing ence to National Dietary Guidelines in Association
dentition, and the pressure applied on the tongue with Oral Health Impact on Quality of Life. Nutrients
by the surrounding teeth (Fig. 22). An enlarged 2018;10(5) [pii:E527].
tongue (macroglossia) can be a developmental 6. Solemdal K, Sandvik L, Willumsen T, et al. The
anomaly, as often seen in Down syndrome, or impact of oral health on taste ability in acutely hospi-
secondary to systemic conditions such as hypo- talized elderly. PLoS One 2012;7(5):e36557.
thyroidism, sarcoidosis, and amyloidosis. A 7. Kalogirou EM, Tosios KI, Nikitakis NG, et al. Tran-
case of generalized lymphangioma was reported sient lingual papillitis: A retrospective study of 11
where macroglossia necessitated partial glos- cases and review of the literature. J Clin Exp Dent
sectomy. There is no specific treatment other 2017;9(1):e157–62.
than identifying sharp edges of teeth that have 8. Kornerup IM, Senye M, Peters E. Transient
developed severe attrition or erosion and lingual papillitis. Quintessence Int 2016;47(10):
smoothening these off to prevent traumatic ulcer- 871–5.
ation of the tongue. 9. Rizos M, Spyropoulos MN. Van der Woude syn-
drome: a review. Cardinal signs, epidemiology,
SUMMARY associated features, differential diagnosis, expres-
sivity, genetic counselling and treatment. Eur J Or-
This article provides an overview of normal oral thod 2004;26(1):17–24.
cavity anatomy within the context of variations of 10. Schutte BC, Basart AM, Watanabe Y, et al. Microde-
normal. It is vital that clinical evaluation of the letions at chromosome bands 1q32-q41 as a cause
oral cavity should include assessment of all of Van der Woude syndrome. Am J Med Genet 1999;
extraoral and intraoral structures. Because many 84(2):145–50.
individuals have variations of normal oral anatomy, 11. Suzuki K, Tsuchihashi Y. New attempt of personal
clinicians should be familiar with them. The varia- identification by means of lip print. J Indian Dent As-
tions often present as distinct oral conditions, soc 1970;42(1):8–9.
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ACKNOWLEDGMENTS 13. Coward RC. The stability of lip pattern characteris-
tics over time. J Forensic Odontostomatol 2007;
Clinical images were obtained at the Department 25(2):40–56.
of Oral Medicine, School of Dental Medicine, Uni- 14. Madani FM, Kuperstein AS. Normal variations of oral
versity of Pennsylvania and Department of Oral anatomy and common oral soft tissue lesions: eval-
Medicine, Sibar Institute of Dental Sciences, Gun- uation and management. Med Clin North Am 2014;
tur, India. Special thanks to Drs Chalatip Chom- 98(6):1281–98.
pund Na Ayudhya (University of Pennsylvania) 15. Gorsky M, Buchner A, Fundoianu-Dayan D, et al.
and Samatha Yalamanchili (Sibar Institute of Fordyce’s granules in the oral mucosa of adult Israeli
Dental Sciences) for assistance with capturing Jews. Community Dent Oral Epidemiol 1986;14(4):
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