Assessment Of Oral Mucosa

The face is observed for fullness suggestive of salivary gland enlargement. Speech is assessed for the smacking sound of the dry oral mucosa sticking to the teeth. The lips are observed for dryness, fissuring, erythema, ulceration, and swelling. The mouth is examined starting with the labial mucosa, the buccal mucosa, the hard/soft palate, the gingiva, the tongue, and the floor of mouth. A piece of gauze is used to dry the floor of the mouth to determine whether pooling occurs as saliva exits the submandibular/ sublingual glands. Bimanual palpation of the submandibular/sublingual glands is used to determine if swelling is present. Saliva is assessed as it is expressed from the right and left parotid papillae, where it exits from Stenson's duct into the oral cavity. The quality of the saliva is noted as clear, cloudy, or thickened, along with the presence or absence of pain/sensitivity with the saliva milking process. Typically saliva exiting the parotid glands will disperse immediately. A hanging drop indicates increased viscosity of the saliva. The body of the parotid gland sits on top of the mas-seter muscle and may be difficult to palpate. The patient may be asked to clench his or her teeth to tense the masseter, allowing delineation between the masseter and the parotid gland. The nature of the enlargement (from protocols developed for the Sjogren's International Collaborative Clinical Alliance; http://sicca.ucsf.edu) can be described as soft (texture of tofu), firm (like an orange), hard (like an apple), nodular (one or more defined masses within the gland that are firm or hard), diffuse (presence of enlargement throughout the glands), or fluctuant (fluid-filled, as in a cyst). The presence or absence of tenderness should be noted. The most common soft tissue oral lesion observed in patients who have SS is an erythematous candidal infection, which will be addressed in further detail below. The temporomandibular joint (TMJ) is assessed for clicking, popping, crepitus, and asymmetry. The possibility of pathology in the TMJ has implications regarding the repetitive action of gum chewing to stimulate saliva. The teeth are examined for the presence of active, recurrent, and incipient caries on the cervical and incisal edges of teeth and unexplained incisal or cervical wear suggestive of a chemical erosive process. The possibility of chemical erosion of the teeth is considered, because there is some evidence that individuals who have salivary dysfunction may not be able to neutralize endogenous/exogenous acids efficiently.2,3

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