Physical Exam: Oral Fixation (Part 1)

October 7, 2007

As opposed to the nose, which gets very little press when it comes to physical exam notation, the mouth exam is quite eventful.  Many things happen in the mouth that attract our attention and hence we tend to write a lot about the mouth.  That is why I am dividing up my articles on the mouth exam. 

The usual doctor scribble on the mouth exam greatly depends on the type of exam.  As a pediatrician (where I write more), I write:

Mouth:  MM’s Moist, Pharynx s E/E

Meaning: Mucous Membranes are Moist, The back of the throat has no redness or gunk on the tonsils (or where the tonsils the tonsils once were).

Yet there are many other aspects of the oral exam, in fact there is a separate degree people can get to just deal with one of the parts (the teeth).  So what we will do in this post is start on the outside and work our way inward.  That paints a strange mental image to me - like an explorer heading to the arctic, except on a huge tongue - but it fits the bill as well as any I could think of.

This is a picture of a famous arctic explorer.  I don’t think he ever went into people’s mouths, however.

The Lips

How could I not start with the most famous lips of all?

Fortunately for the lips, they have a very good spokesmodel.  The lips are also very popular as they are purveyors of the kiss.  Here is an interesting take on the kiss from differing academic perspectives:

Prof. of Computer Science:
A kiss is a few bits of love compiled into a byte.
Prof. of Algebra:
A kiss is two divided by nothing.
Prof. of Geometry:
A kiss is the shortest distance between two straight lines.
Prof. of Physics:
A kiss is the contraction of mouth due to the expansion of the heart.
Prof. of Zoology:
A kiss is the interchange of unisexual salivary bacteria.
Prof. of Physiology:
A kiss is the juxtaposition of two orbicular ors muscles in the state of contraction.
Prof. of Dentistry:
A kiss is infectious and antiseptic.
Prof. of Accountancy:
A kiss is a credit because it is profitable when returned.
Prof. of Economics:
A kiss is that thing for which the demand is higher than the supply.
Prof. of Philosophy:
A kiss is the persecution for the child, ecstasy for the youth and homage for the old.
Prof. of Engineering:
Uh, What? I’m not familiar with that term.

Truthfully, you could add that for physicians, kisses are job security. 

Oh yes, and here is a "Veggie Tales" video about lips that delves into the psychiatric implications of lips.  I wonder what Roy would say.

The exam of the lips really involves two main things: looking at the color, and looking for lesions.  When a person is cyanotic, they have a paucity of oxygenated hemoglobin in their blood.  This is usually due to significant lung problems.  Peripheral cyanosis is blueness to the hands and feet, and happens earlier than central cyanosis, which is blueness to the lips.  Babies have a significant amount of veins around the outside of their lips, and so they can be mistakenly thought to be cyanotic when they are actually just fine.

As far as lip lesions are concerned, the most common one is the herpes viral ulcer.  These are caused by a different strain of the herpes virus than the more "southern" variety, and show up along the distribution of a specific nerve.  They are much more severe when presenting for the first time (primary infection) than in subsequent outbreaks.

These "canker sores" are not to be confused with other mouth ulcers, or "cold sores."  The nomenclature for these are not uniform, so if someone says "cold sore" they may mean a herpetic lesion, or they may mean aphthous ulcers, which are small shallow ulcers that occur in the mouth.  The second type occurs all over the mouth and is far more common that the herpetic variety.  The problem is that many physicians treat aphthous ulcers with medicines for herpes (such as Acyclovir or Valtrex), when it is not at all indicated.  The best treatment for aphthous ulcers is a steroid cream in an oral paste.

Teeth

The musician most famous for his teeth is Dr. Teeth as pictured on the right.

Both older and younger patients of mine lack teeth.  The remainder of the population is scared of dentists.  I have very difficult memories as a child sitting in the waiting room of my dentist, reading Highlights for Children magazine (or at least trying to find the hamburger hidden in the bushes in that picture) with the high whine of a dental drill going on in the background.  My childhood dentist had a sadistic streak to him (I am convinced he dug his own cavities with that pointy thing he used in my mouth), but my current dentist is actually quite nice.  Yet dental fear is profound at times and can lead people to come in to the physician’s office for dental problems.

In this big picture find the paintbrush, shoe, ice-cream pop, hockey stick, glove, radish, trowel, cupcake, sock, hat, hatchet, and toothbrush.

This is too bad, because in medical school we spend about one hour total on the teeth in the four years of our training.  I think Med School profs are afraid of the dentist as well and nobody could get over the "willies" they get even talking about teeth.  That’s my theory.

So what do we do when people ask us about their teeth?  We have several options:

1. Act like we know what we are talking about and use medical jargon to hide the fact that we are clueless.
2. Read up on teeth in our spare time and become experts (this necessitates hours of psychotherapy as we deal with childhood trauma).
3. Say "go ask your dentist" and watch the terrified look come into the patient’s eyes.
4. Change the subject, and start talking about that makes us look much smarter (like the spleen or Bursa of Fabricius).
5. Pretend we had a sudden thing happen in our brain that makes it so we only can speak Romanian.
6. Give a prescription of Naprosyn and Augmentin, hoping that we will hit the cause with one of those medications.

Get the point?  Don’t ask your doctor dental questions.  It makes us compromise our integrity.

Yet there is one dental subject I am well-versed on.  Infants generally don’t go to the dentist until age three (lucky dogs), and so the pediatrician hat I wear makes me the answer man regarding teeth coming in and care for them.  This is fine, because these children are too young to read Highlights for Children so they wouldn’t get the full effect if the did go to the dentist.

Anyhow, here are tidbits about the teeth of young children:

• The first teeth come in around 7 months of age and then appear at a rate of one per month for until the basic set are in
• There is wide variation of this, with some kids getting teeth quite early, and others not getting any until after a year of age (the latest I have seen is 15 months).
• Children without teeth can still eat solids.  I recall when I was taking care of the Veterans at the VA hospital, many of them had no teeth.  They still could, however, eat the steaks from the cafeteria.  Let me point out, that the steaks from the VA cafeteria are not known for their tenderness.  Under the gums is bone, and so it is still possible to chew without teeth.
• Many parents have the habit of leaving a bottle (or cup) in bed with their child.  If the bottle contains milk or juice, the sugars in the liquid will cause significant growth of bacteria that will eat away at the teeth.  This can cause terrible tooth decay.  If your child must have a bottle in bed, use either water or another non-sugar-containing liquid (I recommend "Fruit-2-O").

The Tongue

Giraffes have huge tongues.  My daughter got scared at the Zoo when a giraffe tried to lick her.  I am glad I don’t take care of giraffes.

This tongue probably is coated with lethal acid.

Gene Simmons is the musician most famous for his tongue.  I think he is part giraffe.

OK, so what about the human tongue.  Well, the human tongue can several interesting conditions that we as doctors need to know about.

Infants can get an overgrowth of yeast in the mouth and on the tongue.  This is what is known as Thrush (which some patients mistakenly call "Thrash").  Thrush can cause some discomfort to the child, and is usually treated with medication (although yogurt may also help).  It also can make women very uncomfortable with breastfeeding, so I also recommend treating the woman’s breast with antifungal cream.

Tongues can have other colors as well.  There is a condition called "Black Hairy Tongue" in which the tongue looks….black and hairy.  This is not to be confused with Harry Black tongue, which is a condition suffered by a man named Harry Black who could twist his tongue into shapes like Origami.  He suffered a sad demise when he got his tongue twisted into the shape of a llama and could not get it back.  When the doctors said that he had to get his tongue cut off to survive, he chose to die with his llama rather than have life without his famous tongue.  I am, of course, making all of this up.  Still, it is a good story.

Living in the Southeastern US, there is another tongue condition which often surprises me.  It is called Glossitis Copenhagenous (AKA Skoal Tongue).  You get this when you stuff a wad of a certain type of leaf (grown in this part of the world) into your mouth to chew on.  I have especially been surprised to see this type of tongue problem in little old ladies (LOL’s).   I am not making that one up.

Geographic tongue is a well-named disorder in which the tongue appears to have topographic lines on it.  They are harmless and usually asymptomatic (although some do say that certain food burns on their tongues).  Why does it occur?  Nobody really knows for sure, but some postulate that it may be a message from aliens as to where they will land next.  Others think they are just line thingies on the tongue.

And what about tongue rolling?  I can roll my tongue.  I can even whistle through my tongue when it is rolled (I almost joined the circus for that one).  Here is some interesting info on tongue rolling:

Tongue rolling is the act of rolling the tongue axially into a tube shape. The ability to roll the tongue has been generally believed to depend on genetic inheritance. Tongue rolling was believed to be a dominant trait with simple Mendelian inheritance, and is still commonly used as an example in high school and introductory biology courses. It provided a simple experiment to demonstrate inheritance.

There is little laboratory evidence, though, for the common belief that tongue rolling is inheritable and dominant. A 1975 twin study found that identical twins (who share all of their genes) were no more likely than fraternal twins (who share an average of half) to both have the same phenotype for tongue rolling

Finally, there is the mystifying practice of tongue piercing.  Just why someone would do this is quite beyond my aging brain.  Certainly it is a way to make people know how cool you are - there is no denying that.  I am also aware of some other possible motivations that are not appropriate for discussion before my immature audience (just kidding).  I find myself wondering what the children of tongue-piercing people will do to make their parents upset. 

Well, I have spent a lot of time in the mouth (time to take a shower), and have yet to get to the tonsils and the uvula (that thingy that hangs in the back).  I hope you enjoyed the first part of this expedition to the depths of the world of orality.  I do suggest wearing a raincoat next time.

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