Medical History and Clinical Examination

History taking and clinical examination are essential parts for diagnosing or excluding diseases of the oral cavity. The medical interview gives relevant information about the onset and the previous course of the disease, symptoms, comorbidities, medication, and the patient’s social and professional life. The clinical inspection of the oral cavity allows the examiner to differentiate distinct lesions of the mucosa. Additional inspection of the nasal mucosa, eyes, scalp, nails and wherever possible, skin and anogenital area, should be performed to gain information about possible extra oral manifestations of the disease. On the basis of the medical history and characteristic oral and extra-oral findings, working and differential diagnoses are established. Further investigations (laboratory, imaging) are then initiated if required. It may be necessary to involve other specialties such as otolaryngologists, gastroenterologists, ophthalmologists, dermatologists, gynecologists, urologist, rheumatologists, pediatricians, dentists, oral surgeons, and specialists in oral medicine to establish the diagnosis and initiate treatment. The clinical examination of the oral cavity described in this chapter is simple and can be performed with a wooden tongue depressor, a gauze compress, and a light source and allows a succinct overview. For a full inspection, specialized devices such as head torch and mirrors are required.