The patient should sit up straight, facing the examiner, at a height such that the physician can comfortably look into the mouth. A flashlight or the otoscope may be used as a light source at the bedside, although the head mirror of the ear, nose, and throat (ENT) specialist provides superior illumination.

Palpate all symptomatic or unusual-appearing areas in the mouth and pharynx. (The examiner should wear disposable gloves.) In persons at high risk for carcinoma, the tongue and floor of the mouth should also be palpated because moderate-sized tumors and cysts lying deep within the oral tissues may be found only in this way. Calculi in the submaxillary ducts can be felt. (The salivary glands are discussed in Chapter 14.) A perfectly round, pale, subcutaneous mass in the floor of the mouth is due to the obstruction of a minor
salivary gland; this is called a ranula. The temporomandibular joints can be palpated by placing your fingertips in the external ear canals and having the patient open and close his mouth.

The tongue may be examined for myotonia by placing a tongue blade across the mandibular teeth, having the patient place his tongue on top of the tongue blade, and tapping on the relaxed tongue with a reflex hammer. The reflex hammer should be wrapped in a clean, disposable material. (See Chapter 25 for a description of myotonia as manifested in the hand.)

A great deal has been written about macroglossia, which simply means a large tongue. However, the diagnosis of macroglossia is a matter of opinion because no normal values are available for tongue size. The macroglossia reported in 22% of patients with primary systemic amyloidosis may also be associated with visible changes and palpable stiffness (Kyle and Greipp, 1983), but in Down syndrome and myxedema, it is difficult to be sure how much is macroglossia and how much is simple protrusion.

Some authors have suggested that lateral teeth indentations upon the tongue are presumptive evidence of macroglossia. However, I have seen that finding in a number of patients thought to have neither a disease of the tongue nor any of the known causes of macroglossia, which additionally include neonatal hypoglycemia syndrome (Combs et al., 1966), gargoylism, generalized gangliosidosis, glycogen storage disease, Beckwith-Wiedemann syndrome, acromegaly, and pemphigus vulgaris (Milgraum et al., 1985).

Glossitis means inflammation of the tongue. It can be confusing because the appearance of the tongue is different at different stages of the disease (Beitman et al., 1981). First, there is papillary hypertrophy, then flattening, followed by granular fusion, and finally atrophy. At first, the color of the tongue may be ruddy, “beefy,” or magenta, but when atrophy occurs, the tongue will become pale and smooth and shiny.

Causes of glossitis (some of which overlap) include regional enteritis; alcoholism; sprue; kwashiorkor; pernicious anemia; malabsorption syndromes; deficiencies of pyridoxine, thiamine, niacin, or riboflavin; amyloidosis; and (rarely) the carcinoid syndrome. In one study of patients with iron deficiency anemia, who had an average hemoglobin level of 8.7 g per dL, glossitis was seen in 17% (Kalra et al., 1986).

Haemophilus influenza type b (Hib) can cause an infective glossitis, a less serious condition than the epiglottitis caused by the same disease (vide infra). It is uncommon for other viruses or bacteria to involve the tongue (Schneiderman, 1990).

In geographic tongue, also called migratory glossitis, areas of denuded epithelium appear and are restored to normal, with the pattern changing over periods of a few days. The patient may suffer considerable anxiety from this otherwise harmless condition. Appearances similar to that of geographic tongue can occur in pustular psoriasis, in Reiter syndrome, and with the use of strong mouthwashes (Schneiderman, 1990). Chronic overgrowth of Monilia usually produces a white coating over the tongue but can in some cases have the appearance of a geographic tongue.

A hairy black tongue secondary to broad-spectrum antibiotic administration is usually attributed to Aspergillus niger, a customarily harmless organism that quietly vacates this ecologic niche after antibiotic administration is stopped.

Monilia spots, which look something like flecks of cottage cheese, can be scraped off, although that often leaves a denuded bleeding undersurface. Leukoplakia, by contrast, cannot be scraped off with a tongue blade because it is intrinsic. Candida or Monilia is the culprit in about 96% of chemotherapy-induced fungal infections and is a frequent presenting sign of human immunodeficiency virus (HIV) infection. Other sites commonly involved are the buccal, gingival, palatal, and pharyngeal mucosa, as well as the commissures of the lips.

Hairy leukoplakia is a distinctive lesion that occurs in persons seropositive for the acquired immunodeficiency syndrome (AIDS), who are at increased risk of developing frank AIDS (Centers for Disease Control, 1985; Hollander et al., 1986). It consists of white warty or corrugated projections, particularly on the lateral aspects of the tongue and cheeks (Mindel, 1987). Hairy leukoplakia also occurs in other immunosuppressed conditions, being about as common in kidney transplant recipients as in HIV-positive persons (Greenspan and Greenspan, 1996). It has been described in a patient with chronic renal failure (De Kaminsky et al., 1995) and in an HIV-negative asthmatic patient receiving systemic steroids (Zakrzewska et al., 1995).

Children who have had neonatal jaundice may have biliverdin green teeth later in life. Tetracycline administration (during pregnancy or infancy) may cause brown teeth. Fluorosis may cause brown-and-black pits. Red teeth are seen in erythropoietic porphyria but not in the more common acute intermittent porphyria. Dead teeth become slightly darker than the others.

The teeth should be counted in any case in which a mysterious lesion appears in the jaw because it could be an odontoma. Dr Phil Bromberg of North Carolina first taught me the value of counting the teeth of a patient with a lung abscess—it is better if this is done before a tooth is found on the chest film.

Most cases of loose teeth result from tooth-and-gum disease but can result from jaw tumors or mercurialism. Periodontal disease
is characterized by gingival pyorrhea and gum recession, the latter being the origin of the term “long in the tooth” because it especially afflicts the senescent.

For more than a century, dental amalgam—a mixture of elemental mercury and a silver-dominated metal alloy—has been the most widely used dental-filling material. It has been a source of recurring controversy. Policy differences within Europe made dental amalgam a test case for the European Community’s medical device regulations (Gelband, 1998). Austria, Germany, and Sweden advise restriction of amalgam use or its removal in certain situations (as for children or pregnant women), and some other nations restrict its use through environmental regulations (Wahl, 2001). In the US, extracted amalgam fillings or amalgam-containing teeth must be disposed of as toxic waste.

According to the American Dental Association (ADA), “Dental amalgam (silver filling) is considered a safe, affordable, and durable material that has been used to restore the teeth of more than 100 million Americans…. Issued in late 1997, the FDI World Dental Federation and the World Health Organization consensus statement on dental amalgam stated, ‘No controlled studies have been published demonstrating systemic adverse effects from amalgam restorations’” (American Dental Association, 2002). The only side effects acknowledged by the ADA or the FDA are rare allergic or hypersensitivity reactions (U.S. Food and Drug Administration, 2002). Dentists are constrained against stating otherwise by the ADA code of ethics and the threat of sanctions by licensure boards. ADA Resolution 42H-1986 states: “the removal of amalgam restorations from the nonallergic patient for the alleged purpose of removing toxic substances from the body when such treatment is performed solely at the recommendation of the dentist is improper and unethical” (Odom, 1991).

Despite the widespread use of amalgam, there are no completed long-term large-scale studies of its health effects (Gelband, 1998). There are numerous case reports of severe systemic and neurologic symptoms that resolved upon removal of the fillings (Engel, 1998; Stock, 1926, 1939; Talbot, 1883). Additionally, oral and dental symptoms have been described, including loosened teeth, gingivitis, lichen planus, bleeding gums, and bone loss.

Quantitatively, dental restorations are the most significant non-occupational cumulative source of human exposure to mercury. Mercury exposure averages from 3.9 to 21 µg per day as elemental mercury from dental amalgam, 5.3 to 10.3 µg per day from food sources, 4.3 µg per day as inorganic mercury, and 1 to 6 µg per day as methylmercury from fish (Aposhian, 2004). Additionally, certain vaccines contain up to 25 µg Hg per dose as ethylmercury from thimerosal. Clearly, there are wide differences in individual susceptibilities to any potential untoward effects. Moreover, there are many difficulties in the accurate measurement of the absorbed dose of mercury from amalgams (Eley, 1997a,b).

Count the number of amalgam surfaces in your patients’ fillings. Be prepared to answer the questions of patients, especially those who frequent the Internet. Removal of fillings is not a procedure to be undertaken lightly.

Ask about and document the presence of endodontic restorations (root canals). These could serve as an asymptomatic nidus of infection, as nerves are destroyed in the procedure. Rare reported complications have included multiple liver abscesses (Schiff et al., 2003), precipitation of altitude sickness at a relatively low altitude (Finsterer, 1999), and recurrent pneumococcal bacteremia (Kragsbjerg and Rydman, 2001).