2. Structured extra-oral and soft-tissue examination
Make examination habitual
A consistent sequence reduces missed sites. Explain what you are doing and why — patients accept a thorough soft-tissue check more readily when they understand it is for early cancer detection.
Extra-oral examination
- General appearance: asymmetry, swelling, skin lesions, pallor or cachexia.
- Lymph nodes: systematically palpate cervical chains (submental, submandibular, jugulodigastric, cervical, supraclavicular). Note size, tenderness, fixation and laterality.
- TMJ and muscles of mastication as clinically indicated.
- Lips at rest and on eversion — vermilion and labial mucosa.
Intra-oral soft-tissue sequence (example)
- Labial mucosa and sulci
- Buccal mucosa bilaterally (including occlusal line / linea alba region)
- Hard and soft palate
- Oropharynx / tonsillar pillars (as far as visible) — note any asymmetry
- Tongue — dorsal, lateral borders (especially posterior lateral), ventral surface
- Floor of mouth
- Gingivae and alveolar ridges (edentulous areas included)
- Retromolar regions
Examination tips
- Use good lighting and a mirror; retract systematically.
- Palpate as well as inspect — induration (firmness) is an important red flag.
- Dry the mucosa gently if saliva obscures a white or red patch.
- Ask about symptoms: pain, numbness, ulcer lasting longer than 2–3 weeks, dysphagia, otalgia, unexplained bleeding, voice change, neck lump.
- Compare left and right — asymmetry matters.
High-risk sites
Pay particular attention to:
- Lateral and ventral tongue
- Floor of mouth
- Soft palate / tonsillar region
- Retromolar trigone
- Lip (especially lower lip in outdoor / UV-exposed patients)
Recording the examination
Document negative findings as well as positives (e.g. “soft tissues examined — no suspicious lesions”). If a lesion is present, record site, size, colour, surface, borders, symptoms, duration, and whether it is indurated or fixed.