A complete oral, dental, and throat assessment addresses each of the following as indicated by the patient’s condition and orders, and compares each finding to baseline.
Lips and oral mucosa — moisture, color, and any lesions, ulcers, white plaques, or bleeding.
Tongue — color, coating, lesions, and symmetry.
Gingiva and dentition — bleeding, recession, loose or broken teeth, and dental pain.
Dentures — fit, condition, and any denture-related ulceration or sore spots.
Pharynx — erythema, exudate, swelling, or asymmetry, and any airway concern.
Oral candidiasis — white curd-like plaques, particularly in immunosuppressed, diabetic, inhaled-steroid, or debilitated patients.
Oral hygiene status — plaque, debris, and the patient’s or caregiver’s ability to perform mouth care.
Dry mouth — xerostomia and its causes (medications, dehydration, oxygen) and effect on comfort and intake.
The effect of any oral problem on intake and comfort (cross-reference Nutrition and Taste/Swallowing).
Airway-relevant findings — significant swelling, drooling, or difficulty managing secretions.
