General Pathology

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC I NOT FORPATHOLOGY SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION CHAPTER 1 Introduction to General and Oral Pathology Leslie DeLong © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR CHAPTERDISTRIBUTION 2 Basic Pathology NOT FOR SALE OR DISTRIBUTION Leslie DeLong CHAPTER 3 Inflammation and Repair Leslie DeLong © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONCHAPTER 4 The ImmuneNOT SystemFOR SALE and Immunity OR DISTRIBUTION Leslie DeLong CHAPTER 5 Neoplasia Leslie DeLong © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORCHAPTER SALE 6 ORDevelopmental, DISTRIBUTION Genetic, and CongenitalNOT Disorders FOR SALE OR DISTRIBUTION Leslie DeLong CHAPTER 7 Endocrine Disorders Leslie DeLong © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONCHAPTER 8 Blood Diseases NOT FOR SALE OR DISTRIBUTION Leslie DeLong CHAPTER 9 Gastrointestinal, Neurologic, and Skeletal Disorders Leslie DeLong © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284209372_CH01_001_025.indd 1 26/03/20 5:04 PM CHAPTER © Jones & Bartlett Learning, LLCIntroduction© Jones & Bartlett to General Learning, LLC NOT FOR SALE1 OR DISTRIBUTIONand OralNOT Pathology FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION LEARNING OUTCOMES CHAPTER OUTLINE

1. Define and use the key terms in this chapter. Health and Wellness Disease 2. Discuss the concept of “wellness.” © Jones & Bartlett Learning, LLC Oral Medicine© Jones & Bartlett Learning, LLC 3. Describe the changing roles of the patient and NOT FOR SALE OR DISTRIBUTION The Role NOTof the FORDental SALE Hygienist OR DISTRIBUTION the clinician. Objectives of the Clinical Evaluation 4. Define “oral medicine.” Performing an Extraoral Examination 5. State the objectives of the clinical evaluation. Performing an Intraoral Examination 6. Describe the elements of an extraoral and Describing and Recording Clinical Findings © Jones & Bartlettintraoral Learning, examination LLC or oral cancer screening. © JonesDescribing & Bartlett Radiographic Learning, Findings LLC NOT FOR SALE7. List OR observ DISTRIBUTIONations that might suggest that a lesion NOT FORDetermining SALE a OR Diagnosis DISTRIBUTION is benign or malignant. Differential Diagnosis Definitive Diagnosis 8. Note the elements of a complete clinical description. 9. List the element©s thatJones should & beBartlett included Learning, in a LLC © Jones & Bartlett Learning, LLC description of radiographic findings. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 10. Write a complete clinical description of a sample case study. 11. Describe the steps involved in reaching a differential diagnosis. 12.© DescribJonese &possible Bartlett ways Learning,of determining LLC a © Jones & Bartlett Learning, LLC NOTdefinitive FOR SALEdiagnosis. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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KEY TERMS © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Abrasion Induration NOT FOR SALEAmalgam ORtattoo DISTRIBUTION NOTLesion FOR SALE OR DISTRIBUTION Atypical Localized Benign Lymphadenopathy Biopsy Macule Bulla Malignant Circumscribed © Jones & Bartlett Learning, LLCMelanoma © Jones & Bartlett Learning, LLC Coalesce Mixed Convergence NOT FOR SALE OR DISTRIBUTIONMultilocular NOT FOR SALE OR DISTRIBUTION Corrugated Nodule Crusted Oral medicine Definitive diagnosis Papillary Differential diagnosis Papule Divergence Patch Endogenous© Jones & Bartlett Learning, LLC Pedunculated© Jones & Bartlett Learning, LLC EndophyticNOT FOR SALE OR DISTRIBUTION Plaque NOT FOR SALE OR DISTRIBUTION Erosion Pseudomembrane Erythematic Pustule Exogenous Radiolucent Exophytic Radiopaque Exudate Resorption © Jones & PurulentBartlett Learning, LLC © JonesSessile & Bartlett Learning, LLC NOT FOR SALEFissured OR DISTRIBUTION NOTTumor FOR SALE OR DISTRIBUTION Fluctuant Ulcer Generalized Unilocular Homeostasis Vesicle

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC RELATED CLINICALNOT PROTOCOLFOR SALE OR DISTRIBUTIONdesire. People everywhere areNOT looking FOR at different SALE ORmethods DISTRIBUTION of achieving “health” as it is defined today. They are seeing #15 Office Protocol for Identifying Suspected Family Violence that many alternative and complementary forms of medicine have a place in the health care system. The concept of “wellness” places a strong focus on the active role of the Health© Jones and & Wellness Bartlett Learning, LLC patient and© the Jones importance & Bartlett of the total Learning, well-being LLCof the NOT FOR SALE OR DISTRIBUTION person. TheNOT US government FOR SALE has proposedOR DISTRIBUTION four all-embrac- Pathology is defined as the study of disease. However, before ing goals in its 10-year agenda for improving the nation’s learning about disease, it is necessary to have a clear defi- health, Healthy People 2020. These goals are (1) attain high- nition of health. In 1948, the World Health Organization quality, longer lives free of preventable disease, disability, defined health as “a state of complete physical, mental, and injury, and premature death; (2) achieve health equity, © Jones &social Bartlett well-being—not Learning, merely LLC the absence of disease or infir©- Joneseliminate & Bartlettdisparities, Learning, and improve LLCthe health of all groups; NOT FORmity.” SALE Almost OR 50DISTRIBUTION years later, Stedman’s Medical DictionaryNOT (3) FOR create SALE social ORand physicalDISTRIBUTION environments that promote for the Health Professions, 7th edition, defines health as “a good health for all; and (4) promote quality of life, healthy state characterized by anatomical, physiological, and psycho- development, and healthy behaviors across all life stages logical integrity, ability to perform personally valued family, (Healthy People 2020, 2016). Healthy People 2020 reflects work, and community roles; ability to deal with physical, the changing attitudes of Americans and encourages estab- biological, psychological© andJones social & stress; Bartlett a feeling Learning, of well- LLClishing a sense of personal responsibility© Jones as & the Bartlett key to good Learning, LLC being; and freedom fromNOT the FOR risk of SALE disease ORand untimelyDISTRIBUTION health. Students pursuing a careerNOT in FOR health SALE care study OR the DISTRIBUTION death.” The definition and concept of health comprise a wide healthy body in anatomy and physiology and other subjects range of physical, emotional, and spiritual components. throughout their formal education. This text draws on this The concept of health care has rapidly evolved over the knowledge extensively to provide a study of disease states. past several decades, and many paradigms or models for health© careJones have been& Bartlett examined Learning, and modified LLC or eliminated. Disease© Jones & Bartlett Learning, LLC TheNOT role of FOR the health SALE care OR provider DISTRIBUTION has changed from dic- NOT FOR SALE OR DISTRIBUTION tator to advisor and facilitator. The role of the patient has Defining disease is far simpler than defining health. also changed. No longer do patients have to be passive par- Stedman’s Medical Dictionary for the Dental Professions, ticipants; they can be dynamic partners in their own health 2nd edition, defines disease as “an interruption, cessation, care. The Internet has added a new dimension to the con- or disorder of a body, system, or organ structure or func- © Jones &cept Bartlett of access Learning, to health care LLC information, enabling people© Jonestion” or & “a Bartlett morbid entity Learning, ordinarily LLC characterized by two or NOT FORto SALE become OR informed DISTRIBUTION consumers of health care if they soNOT more FOR of SALEthe following OR criteria:DISTRIBUTION recognized etiologic agent(s),

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The dental profession has known for years that the B O X © Jones & Bartlett Learning, LLC © Jones & 1.1Bartlett Learning, LLC mouth is not divorced from the rest of the body but is an NOT FOR SALE ORMajor DISTRIBUTION Findings of “Oral Health in America: NOT FOR SALE OR DISTRIBUTION A Report of the Surgeon General” integral part of it. In the year 2000, the Surgeon General of the United States released “Oral Health in America: ■ Oral diseases and disorders in and of themselves affect health and well-being throughout life. A Report of the Surgeon General.” This report was the first ■ Safe and effective measures exist to prevent the most of its kind, and its intent was to alert Americans to the common dental diseases—dental caries and periodontal full meaning of oral health and its importance to general diseases. © Jones & Bartlett Learning, LLChealth and well-being (USDHHS,© Jones 2000). Boxes& Bartlett 1.1 and Learning,1.2 LLC ■ Lifestyle behaviors thatNOT affect FOR general SALE health such OR as DISTRIBUTIONtobacco summarize the major findingsNOT of the FOR report SALE and the OR major DISTRIBUTION use, excessive alcohol use, and poor dietary choices affect oral and craniofacial health as well. functional and social implications of oral and craniofa- ■ There are profound and consequential oral health disparities cial diseases that are identified in the report. What hap- within the US population. pens in the mouth can and does affect the rest of the body. ■ More information is needed to improve America’s oral health Research, while not proving a causal relationship, appears and© Joneseliminate health& Bartlett disparities. Learning, LLC to support the© conceptJones that & Bartlettperiodontal Learning, infections may LLC have ■ TheNOT mouth FOR reflects SALE general OR health DISTRIBUTION and well-being. NOT FOR SALE OR DISTRIBUTION ■ Oral diseases and conditions are associated with other an impact on the development, severity, or progression of health problems. heart disease, stroke, diabetes, respiratory disease, and pre- ■ Scientific research is key to further reduction in the burden term low-birth-weight babies. In addition, many pathologic of diseases and disorders that affect the face, mouth, and conditions and diseases have oral manifestations that may teeth. © Jones & Bartlett Learning, LLC © Jonesappear & in Bartlettthe early stages Learning, of the illness, LLC possibly prior to any From U.S. Department of Health and Human Services. Oral health in other symptoms. Although the importance of oral health NOT FOR SALEAmerica: A ORreport DISTRIBUTIONof the Surgeon General. Rockville: U.S. Department of NOTin FOR the context SALE of OR total DISTRIBUTION health is known by many, there are Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. many more individuals who are not aware of the connec- tion. Health care professionals, including dental health care professionals, are entrusted with the difficult task of helping patients to achieve and maintain an optimal state of health. identifiable group of© signs Jones and symptoms,& Bartlett or Learning, consistent LLC © Jones & Bartlett Learning, LLC anatomical alterations.”NOT The FORdiscussion SALE of disease OR DISTRIBUTION does not NOT FOR SALE OR DISTRIBUTION specifically refer to an infection with a microorganism; it Oral Medicine includes any instance in which there is a change or altera- Oral medicine is a specialized study within the scope of tion in homeostasis, or balance, within the systems of the dental medicine. Although the concept of an interrelation- body. Knowledge of the processes associated with disease ship between dentistry and medicine has been recognized is an© essential Jones part & ofBartlett the practice Learning, of dental hygiene. LLC Dental for centuries,© the Jones integration & Bartlett of dentistry Learning, and medicine LLC was hygienistsNOT mustFOR be SALE aware of OR the DISTRIBUTIONimpact disease has on the greatly enhancedNOT inFOR 1946 SALEwith the OR publication DISTRIBUTION of “Burket’s functioning of the human body. Oral Medicine” text now in its 12 edition. The discipline

B O X © Jones & 1.2Bartlett Functional Learning, and Social LLC Implications of Oral and © Jonesconditions & Bartlett include tooth Learning, loss, diminished LLC salivary functions, Craniofacial Diseases as Reported in “Oral orofacial pain conditions such as temporomandibular disorders, NOT FOR SALE ORHealth DISTRIBUTION in America: A Report of the Surgeon NOT FORalterations SALE in taste, OR and DISTRIBUTION functional limitations of prosthetic General” replacements. ■ Orofacial pain, as a symptom of untreated dental and oral ■ Oral health is related to well-being and quality of life as problems and as a condition in and of itself, is a major measured along functional, psychosocial, and economic source of diminished quality of life. It is associated with sleep dimensions. Diet, nutrition, sleep, psychological status, social deprivation, depression, and multiple adverse psychosocial interaction, school, and© workJones are affected & Bartlett by impaired Learning, oral and LLCoutcomes. © Jones & Bartlett Learning, LLC craniofacial health. NOT FOR SALE OR DISTRIBUTION ■ Self-reported impacts of oral conditionsNOT FOR on social SALE function OR DISTRIBUTION ■ Cultural values influence oral and craniofacial health and well- include limitations in verbal and nonverbal communication, being and can play an important role in care utilization practices social interaction, and intimacy. Individuals with facial and in perpetuating acceptable oral health and facial norms. disfigurements due to craniofacial diseases and conditions and ■ Oral and craniofacial diseases and their treatment place their treatments may experience loss of self-image and self- a burden on society in the form of lost days and years of esteem, anxiety, depression, and social stigma; these in turn ©productive Jones work. & AcuteBartlett dental conditionsLearning, contribute LLC to a may limit educational,© Jones career, & Bartlett and marital Learning, opportunities and LLC NOTrange of FORproblems SALE for employed OR adults,DISTRIBUTION including restricted affect otherNOT social FORrelations. SALE OR DISTRIBUTION activity, bed days, and work loss, and school loss for children. ■ Reduced oral health–related quality of life is associated with In addition, conditions such as oral and pharyngeal cancers poor clinical status and reduced access to care. contribute to premature death and can be measured by years of life lost. Taken from U.S. Department of Health and Human Services. Oral health in ■ Oral and craniofacial diseases and conditions contribute America: A report of the Surgeon General. Rockville: U.S. Department of © Jones & Bartlettto compromised Learning, ability to bite, LLC chew, and swallow foods; © JonesHealth and & HumanBartlett Services, Learning, National Institute LLC of Dental and Craniofacial limitations in food selection; and poor nutrition. These Research, National Institutes of Health, 2000. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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was created to expand the scope and depth of the dentist’s sometimes before the patient knows they exist, and to call © Jones &knowledge Bartlett and Learning, skills regarding LLC pathophysiology, pharma©- Jonesattention & Bartlettto these abnormalities. Learning, LLCFollowing collaboration NOT FORcology, SALE diagnosis, OR DISTRIBUTION and primarily nonsurgical managementNOT with FOR the SALE dentist, OR the DISTRIBUTIONdental hygienist may be the person of medically complex patients including those with medi- who assists the patient in obtaining the necessary care. cally related conditions affecting the oral and maxillofacial region. Oral medicine is a specialty of dentistry through- Objectives of the Clinical Evaluation out the world and is an emerging specialty within the US dental and medical educational© Jones system. & Bartlett Emphasis Learning, is placed LLCEach patient must be thoroughly© Jonesassessed for& Bartlettany indication Learning, LLC on treating the patientNOT from FOR a “whole SALE body” OR perspective. DISTRIBUTION of medical and/or oral problemsNOT prior FOR to dentalSALE or ORdental DISTRIBUTION Current curriculum guidelines for dental hygiene educa- hygiene procedures. The extraoral and intraoral examination have stressed providing students with an integrative tions compose a large portion of this assessment, and while background in oral medicine to address this total patient they are generally referred to as the extraoral and intraoral concept. Sections on Oral Medicine Considerations high- examinations, together they make up the oral cancer screen- lighting© Jones this concept & Bartlett are included Learning, throughout LLC this text. ing examination.© Jones Although & theseBartlett examinations Learning, may take LLC less NOT FOR SALE OR DISTRIBUTION time to performNOT compared FOR SALEwith a periodontal OR DISTRIBUTION examination or a dental charting, they are extremely important. Information The Role of the Dental Hygienist from the examinations is essential in determining if there is Healthy People 2020 brings the role of the dental hygien- any indication of deviation from normal, not only in the oral ist to the forefront of prevention of not only dental disease cavity but also in the body as a whole. Findings may be sug- © Jones &but Bartlett other illnesses Learning, as well byLLC setting goals to “increase the© Jonesgestive & of Bartlettoral or pharyngeal Learning, cancer LLCor of systemic conditions NOT FORproportion SALE OR of adultsDISTRIBUTION who receive preventive interventionsNOT that FOR may SALE manifest OR in theDISTRIBUTION oral cavity. The American Cancer in dental offices” (Healthy People 2020, 2016). Three goals Society estimates 69% of oral cancers are diagnosed at late specifically include the dental hygienist (in addition to the stages, when regional and distant metastasis have already dentist) in the endeavor to (1) increase the number of adults occurred (American Cancer Society, 2016). Late stage diag- receiving information or counseling in regard to tobacco noses complicate treatment and lead to low survival rates. cessation, (2) increase© the Jones number & of Bartlett adults receiving Learning, an LLCThe 5-year survival rate for all ©stages Jones combined & Bartlett is 63%, with Learning, a LLC oral and pharyngeal NOTcancer FORscreening, SALE and OR (3) DISTRIBUTIONincrease range of 83% for localized lesionsNOT to 38% FOR for distant SALE metastasis OR DISTRIBUTION the number of adults being tested or referred for glycemic (Howlader et al., 2016). If more of these cancers were found (blood sugar) control (Healthy People 2020, 2016). The den- at an earlier stage, survival rates would increase and morbid- tal hygienist is uniquely qualified, as the dental health care ity (loss of function and disfigurement) would decrease. The team’s prevention specialist, to make observations regard- American Cancer Society estimates 48,330 individuals in the ing a© patient’s Jones total & healthBartlett as it relatesLearning, to oral health LLC and vice United States© willJones be diagnosed & Bartlett with oralLearning, or oropharyngeal LLC versa.NOT The FORdental SALEhygienist OR is also DISTRIBUTION in a position to develop cancer in 2016,NOT and FOR an estimated SALE 9,570 OR will DISTRIBUTION die from the dis- strategies directed toward education and the early detec- ease in 2016 (American Cancer Society, 2016). tion and prevention of disease. Patients schedule preventive Positive findings during this examination can prompt appointments two to four times per year; therefore, the den- the dental team to order additional tests or procedures to tal hygienist is in a key position to recognize abnormalities, determine a diagnosis for the condition. The dental hygiene © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION APPLICATION 1.1. Research in Action Raising Public Awareness of Head and Neck United Kingdom (Awojobi et al., 2012; Luryi et al., 2014; Riley Cancers and Their Risk Factors et al., 2013; Walsh et al., 2013) all conclude there is a lack of public awareness of head and neck cancers including oropha- More than 15 years ago,© Jonesstudies done & Bartlett by Horowitz Learning, et al. and LLCryngeal cancers. They found that© mostJones individuals & Bartlett reported Learning, LLC Forrest et al. found NOTthat dental FOR hygienists SALE didOR not DISTRIBUTION consis- knowing little or nothing about theNOT cancers FOR and SALE risk factors, OR DISTRIBUTION tently provide oral cancer screening examinations for their most did not know if their dentist had ever examined them for patients even though most knew it should be done (Forrest signs of cancer. The study done in the United Kingdom also et al., 2001; Horowitz et al., 2002). When these findings were found that 92% of the patients wanted their dentist to inform released, increased efforts were made to educate the dental them of the examination and 97% wanted the dentist to help community about the significance of performing the screening them lower their risk factors (Awojobi et al., 2012). examinations.© Jones Statistics& Bartlett show Learning, that these efforts LLC have been © Jones & Bartlett Learning, LLC relativelyNOT FORsuccessful. SALE In 2013, OR WalshDISTRIBUTION et al. studied approxi- Many of the NOTpatients FOR surveyed SALE by the OR various DISTRIBUTION studies who ini- mately 1,500 hygienists from across the United States and tially reported never having an oral cancer screening exami- found that 94% self-reported performing the examinations. nation changed their answers after they were provided with However, they also found that only 51% reported palpat- a description of the examination. This finding shows that the ing the structures of the neck area and only 76% routinely dental community needs to place much more emphasis on informed the patient of the reason for the examination (Walsh educating our patients and helping them to identify and lessen © Jones & Bartlettet al., 2013). Learning, Studies done LLC in the United States and in the© Jonesor eliminate & Bartlett their risk factors.Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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B O X © Jones & Bartlett Learning, LLC © Jones & 1.3Bartlett Learning, LLC NOT FOR SALE ORObjectives DISTRIBUTION of the Clinical Evaluation NOT FOR SALE OR DISTRIBUTION 1. Screen for oral cancer 2. Determine whether the patient is well enough to continue dental treatment 3. Determine the need for medical or other consultations 4. Enable early diagnosis of pathology 5. Determine possible© treatment Jones modifications & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 6. Prepare and recordNOT baseline FOR patient SALE assessment OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION information 7. Review and update baseline assessment information 8. Determine whether additional diagnostic procedures are necessary © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC appointmentNOT FOR may haveSALE to be OR postponed DISTRIBUTION to obtain a medical FIGURE 1.1. Supraorbital.NOT FOR Facial SALE symmetry OR observed DISTRIBUTION from the supraor- consultation based on findings during this examination (see bital aspect. Box 1.3 for a listing of objectives of the clinical evaluation). Some positive findings may cause the dental professional discussed in this text are referred to as lesions. A lesion is a to suspect intentional trauma or neglect. (Refer to Clinical wound or a distinct area in which a pathologic change has © Jones &Protocol Bartlett #15 Learning,for more information LLC on family violence and© Jonestaken &place. Bartlett The moreLearning, normal and LLC abnormal entities the NOT FORsuggestions SALE OR for DISTRIBUTION recognizing and managing this situation.)NOThygienist FOR SALE observes OR over DISTRIBUTION time, the more observant he or she will become. With experience, the hygienist will see things Performing an Extraoral Examination that cause alarm as well as notice things that do not. The extraoral component of the examination should include The following is a suggested order for performing the extraoral examination: a general assessment of© the Jones patient, & an Bartlett assessment Learning, of all vis- LLC © Jones & Bartlett Learning, LLC ■ ible areas of skin, and NOTan assessment FOR SALE of the headOR andDISTRIBUTION neck Observe the eyes and the NOTpupils. FOR Figure SALE 1.2 depicts OR an DISTRIBUTION area. This assessment starts with the dental hygienist deter- abnormal area at the inner canthus of the eye called a mining if there are any noticeable physical abnormalities as pterygium that may be caused by excessive exposure to the patient walks to the dental chair. The patient’s gait, pos- sunlight or may be associated with lichen planus (see ture, and how he or she sits in the chair should be observed Chapter 13) or other skin disorders. This type of finding as well© asJones the patient’s & Bartlett speech; anyLearning, abnormalities LLC should be should be© noted, Jones and & the Bartlett patient should Learning, be questioned LLC notedNOT in the FOR patient’s SALE record. OR All visibleDISTRIBUTION areas of the patient’s about it NOTfor a possible FOR SALE referral. OR Hold DISTRIBUTION up the eyelids in skin may be observed while gathering medical and dental older adults so the entire eyelid can be observed (Fig. 1.3). history information and obtaining vital signs. Any abnor- ■ Look at the ears and the skin in back of the ears because malities should be addressed using follow-up questions. patients are not able to see this area themselves, and it The answers to these follow-up questions will determine the can be easily forgotten. Also check the area at the back of © Jones &next Bartlett course ofLearning, action. Patients LLC will respond to most ques©- Jonesthe &neck, Bartlett which can Learning, be observed LLC while the lymph nodes tions that are asked in a professional manner, and most are are being palpated. Acanthosis nigricans, a darkening NOT FORvery SALE willing OR to discussDISTRIBUTION their physical status, especially whenNOT FORand thickeningSALE OR of theDISTRIBUTION skin at the nape of the neck, is informed of the necessity for the information. associated with prediabetes and would warrant a refer- There is no set sequence for performing a head and ral to a physician (see Chapter 7 and Figure 7.21). neck examination; however, it should be done the same way every time. A systematic© Jones procedure & Bartlett for these Learning, exami- LLC © Jones & Bartlett Learning, LLC nations increases the amount of attention paid to what is being examined, insteadNOT of what FOR should SALE be examined OR DISTRIBUTION next, NOT FOR SALE OR DISTRIBUTION and wondering if something was omitted. A systematic approach will also make the examinations faster and more reliable. Always look first (visual) and then palpate (tactile), pressing© Jones the tissue & betweenBartlett fingers Learning, or against LLC a firm struc- © Jones & Bartlett Learning, LLC ture such as bone in every area examined, even if there are no visibleNOT abnormalities.FOR SALE The OR DISTRIBUTIONhead and neck area should NOT FOR SALE OR DISTRIBUTION be examined for symmetry by observing the patient from all angles including the supraorbital area (Fig. 1.1). The patient’s profile should be classified as mesognathic, prog- © Jones &nathic, Bartlett or retrognathic. Learning, Observe LLC the skin of the face, look for© Jones & Bartlett Learning, LLC acne, moles (nevi), lumps or bumps, or roughened areas of NOT FORskin. SALE Many OR of the DISTRIBUTION conditions or characteristics of conditionsNOT FIGURE FOR 1.2. SALEPterygium. OR A pterygium DISTRIBUTION is an overgrowth of tissue (conjunctiva).

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■ While palpating the nodes, be aware of the salivary © Jones & Bartlett Learning, LLC © Jonesglands & Bartlettin the area Learning, and extend LLC the palpations to the NOT FOR SALE OR DISTRIBUTION NOT FORparotid SALE and under OR theDISTRIBUTION mandible for the submandibular. Look for areas of swelling, induration, or tenderness. ■ Examine the thyroid gland by pressing one side of the gland against the thyroid cartilage while holding the other side of the gland (Fig. 1.7). Then check to make sure the © Jones & Bartlett Learning, LLCthyroid cartilage moves symmetrically© Jones during & Bartlett swallowing. Learning, LLC NOT FOR SALE OR DISTRIBUTION ■ Bilateral palpation of theNOT temporomandibular FOR SALE ORjoints DISTRIBUTION should be done next. The function of the joint is best observed from a supraorbital position while the patient is opening and closing the mouth and moving the jaw from side to side (Fig. 1.8). In addition, examine the © Jones & Bartlett Learning, LLC patient for© anyJones limitations & Bartlett in opening Learning, the mouth LLC or for FIGURE 1.3. Examine the upper eyelid. Stretch the upper eyelid so that NOT FOR SALE OR DISTRIBUTION any joint NOTsounds. FOR Ask aboutSALE joint OR tenderness DISTRIBUTION or modifi- you can observe all areas of the lid. cations in food choices made to accommodate painful joint function. ■ Palpate the occipital, auricular, buccal, submandibular, Any abnormalities should be accurately recorded in © Jones & Bartlettsubmental, Learning, supraclavicular, LLC and cervical chain, including© Jonesthe patient’s & Bartlett record. Learning, Terminology LLC and a suggested for- the deep, superficial, and posterior lymph nodes. Figure 1.4 NOT FOR SALE OR DISTRIBUTION NOTmat FOR for SALErecording OR descriptions DISTRIBUTION of abnormal conditions shows the locations of these lymph nodes. Findings that are presented following the discussion of the intraoral should be noted include induration or hardening, tender- examination. ness, mobility or movability, and, if abnormal, whether one or more nodes are involved. Another term used to describe Performing an Intraoral Examination enlarged, indurated, ©and Jones sometimes & Bartletttender lymph Learning, nodes is LLC © Jones & Bartlett Learning, LLC lymphadenopathy. FiguresNOT 1.5FOR and SALE1.6 show OR clinically DISTRIBUTION vis- The intraoral examination is NOTa continuation FOR SALE of the extraoral OR DISTRIBUTION ible cervical lymphadenopathy. examination and may overlap in several areas, especially near

FIGURE 1.4. Lymph nodes of the head and neck. The location of the lymph nodes to be palpated during the extraoral© examination.Jones & (From Bartlett Nield-Gehrig Learning, JS. Patient LLC © Jones & Bartlett Learning, LLC assessment tutorials. 2nd ed. Philadelphia: Wolters KluwerNOT Health/Lippincott FOR SALE Williams &OR Wilkins, DISTRIBUTION 2010.) NOT FOR SALE OR DISTRIBUTION

Postauricular Preauricular © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC

NOT FOR SALE OR DISTRIBUTION NOTOccipital FOR SALE OR DISTRIBUTION

Submandibular

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Submental Cervical posterior chain Cervical © Jones & Bartlett Learning, LLC © Jones anterior& Bartlett Learning, LLC chain NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Supraclavicular © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION FIGURE 1.7. ExamineNOT theFOR thyroid SALE gland. Gently OR press DISTRIBUTION the thyroid gland against the thyroid cartilage with the fingers of one hand while you hold the other side of the gland steady against the cartilage.

prior to the start of the examination. Figure 1.9 depicts © Jones & Bartlett Learning, LLC © Jonesthe &oropharyngeal Bartlett Learning, area of a patient LLC who has a problem NOT FOR SALE OR DISTRIBUTION NOT FORwith theSALE retention OR DISTRIBUTIONof food particles within the surface tissues of the tonsils. She complained of a bad mouth odor and stated that occasionally she was able to remove the packed food from these areas with a toothbrush. ■ Next, visualize and palpate the soft and hard palates and © Jones & Bartlett Learning, LLCthe maxillary tuberosity. © Jones & Bartlett Learning, LLC FIGURE 1.5. Lymphadenopathy. Clinically visible enlarged lymph node in anterior cervical chain. (CourtesyNOT ofFOR Dr. Carolyn SALE Bentley.) OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

the lips and buccal mucosa. Again, the sequence of the examination is not as important as developing a routine, systematic approach.© Jones Repeating & Bartlett the same Learning, steps over andLLC over again © Jones & Bartlett Learning, LLC will increase the accuracy of the examination and decrease the chanceNOT FORanything SALE will be OR missed. DISTRIBUTION The following is a sug- NOT FOR SALE OR DISTRIBUTION gested sequence for performing the intraoral examination. ■ The oropharynx is a common place to start. Make sure the entire area of the oropharynx is observed. There © Jones & Bartlettmay be only Learning, one chance LLC to see the area because some© Jones & Bartlett Learning, LLC patients have a problem with gagging and after they NOT FOR SALErealize ORwhat DISTRIBUTION is being done, they may become “difficult,”NOT A FOR SALE OR DISTRIBUTION even though they have been informed of the procedures

B FIGURE 1.8. Examine the temporomandibular joint (TMJ). Position yourself to observe the mouth opening and closing and moving side to © Jones &FIGURE Bartlett 1.6. Lymphadenopathy. Learning, ClinicallyLLC visible enlarged lymph node © Jonesside from & the Bartlett supraorbital Learning, aspect while you LLC bimanually palpate the TMJ. NOT FORin SALE posterior ORcervical DISTRIBUTION chain. NOTA. FOR Opening SALE and closing. OR B. DISTRIBUTIONMoving from side to side.

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC FIGURENOT 1.9. ExamineFOR theSALE oropharynx. OR Get DISTRIBUTION a good look at the entire oro- FIGURE 1.11. NOTExamine FOR the floor SALE of the mouth.OR UseDISTRIBUTION the fingers of your pharynx as quickly as possible. Notice the yellowish areas of food debris intraoral hand to press the tissues of the floor of the mouth against the stuck in the craters of the tonsillar tissue. fingers of your extraoral hand.

■ Stretch out the buccal mucosa (Fig. 1.10) and roll the ■ Assess the amount and quality of saliva by observation © Jones & Bartlettlabial mucosa Learning, over your LLCfingers and thumbs so you can© Jonesand & by Bartlettmilking the Learning, parotid gland. LLC Remember thick foamy NOT FOR SALEvisualize OR the DISTRIBUTION entire surface of each. Palpate all of the softNOT FORsaliva SALE is usually OR a sign DISTRIBUTION of a very dry mouth. tissues after they have been observed. ■ Parafunctional habits such as bruxism (grinding) or ■ Examine the mandible; stretch the alveolar mucosa at clenching also need to be assessed and, if present, the floor of the mouth to see any areas that may be hid- noted in the record. ing under the inferior border of the mandible. Palpate the entire mandible© from Jones the inferior & Bartlett border to Learning, the angle LLCDescribing and Recording© ClinicalJones &Findings Bartlett Learning, LLC of the mandible. NOT FOR SALE OR DISTRIBUTIONWritten descriptions of an NOTabnormality FOR SALEmust provideOR DISTRIBUTION ■ Next, examine the floor of the mouth; use bimanual pal- enough detail so another professional the patient may need pation to press the structures against the fingers of your to see has adequate information to decide whether the extraoral hand (Fig. 1.11). Look for any areas of color abnormality is resolving or becoming worse. Remember, change, tenderness, induration, or masses. the patient record is a legal document and should stand ■ © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Hold the tongue with a gauze square and gently roll the up to legal scrutiny if it ever becomes necessary. Intraoral tongueNOT over FOR on SALE one side OR to observeDISTRIBUTION the lateral border, photographsNOT are being FOR used SALE in many OR practices DISTRIBUTION to provide and then repeat for the other side (Fig. 1.12). Observe an adjunct to the written description for future compari- the dorsal and ventral surfaces and then palpate the son, but there must always be a written description in the entire tongue. After removing the gauze, observe the tip patient’s record. Certain observations will cause the den- of the tongue. tal hygienist more concern than others. Some findings are © Jones & ■ BartlettFinally, observe Learning, and palpate LLC the attached gingiva on the© Jonesoften associated& Bartlett with Learning, very aggressive, LLC malignant or cancer- NOT FOR SALEmaxillary OR and DISTRIBUTION mandibular arches. NOTous FOR conditions, SALE while OR othersDISTRIBUTION may indicate relatively benign

FIGURE 1.10. Examine the buccal mucosa. Stretch the buccal mucosa FIGURE 1.12. Examine the lateral borders of the tongue. Turn the © Jones &away Bartlett from the maxillary Learning, and mandibular LLC arches to examine the entire © Jonestongue over& Bartlett rather than pulling Learning, the tongue out.LLC It is not as uncomfortable NOT FORsurface. SALE OR DISTRIBUTION NOTand FOR more SALEcan be seen OR than DISTRIBUTION if the tongue is straight.

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B O X © JonesB O X& Bartlett Learning, LLC © Jones & 1.4Bartlett Learning, LLC 1.5 NOT FOR SALE ORObservations DISTRIBUTION Suggestive of Benign versus NOT FOR SALEEffective OR Use DISTRIBUTION of Follow-Up Questions Malignant or Aggressive Lesions Our ability to effectively obtain information from our patients 1. Observations implying a more benign condition depends on many factors, which include showing genuine a. Nonulcerated lesions concern for them, having a nonjudgmental attitude, and asking b. Bilateral involvement the right question in the right way. The patient’s age and level of c. Sharply demarcated borders health literacy should be considered when deciding how to word a d. Multiple areas of© involvement Jones & Bartlett Learning, LLCquestion. The use of everyday language© Jones rather than& Bartlett professional Learning, LLC e. Elevated, soft, andNOT movable FOR lesions SALE OR DISTRIBUTIONjargon will usually get a more reliableNOT response. FOR The SALE following OR are DISTRIBUTION f. Lesions that have a direct cause-and-effect relationship some suggestions for obtaining general information. Follow-up 2. Observations implying a more aggressive, possibly questions related to specific conditions will be included in the dis- malignant condition cussion of those conditions. The word “lesion” can be replaced a. Paresthesia with a term that better describes your patient’s condition. b. Single area of involvement ■ When did you first notice this lesion? ©c. Jones Poorly defined & Bartlett and ragged Learning, borders LLC © Jones & Bartlett Learning, LLC ■ How long has it been present? d. Flat, indurated, and fixed lesions NOT FOR SALE OR DISTRIBUTION ■ Has it changed,NOT gottenFOR better SALE or worse? OR DISTRIBUTION e. Alteration of the periodontal ligament space and/or ■ Have you had the same or similar type of lesion before? In lamina dura the same place? f. Mixed red and white lesions and velvety red lesions ■ Do you have more lesions anywhere else? g. Lesions on the lateral borders of the tongue, soft palate, ■ Has anyone else in your family had the same type of lesion? floor of the mouth, and lip ■ Was there any trauma to the area? h. Radiographic evidence of bone expansion or root © Jones & Bartlett Learning, LLC © Jones ■ Is there& Bartlett pain or any Learning, other type of different LLC sensation? erosion, displacement, or resorption NOT FOR SALE OR DISTRIBUTION NOT FOR ■ On a SALE scale of 1OR to 10 DISTRIBUTION how would you rate your pain? ■ Have you been treating it? With what? Has it been effective? ■ Have you had any new health problems recently or since your or noncancerous and less aggressive conditions. While last visit? ■ Are you taking any new medications? these findings are often indicators of severity, do not be ■ Have you changed your diet? fooled into thinking this© isJones always the & caseBartlett because Learning, even the LLC © Jones & Bartlett Learning, LLC most innocuous lookingNOT lesion FOR may very SALE well beOR malignant DISTRIBUTION. NOT FOR SALE OR DISTRIBUTION Box 1.4 lists some observations that are associated with ■ Distribution and definition—Terms that describe distri- benign conditions and those that might imply a more seri- bution include the following: ous or malignant condition. The description of unknown ● Localized, or found in one area only. The term “focal” lesions or other abnormalities should include the following: can also be used (Fig. 1.13). ■ History—Very© Jones & often, Bartlett there Learning, is no history LLC of an oral ● Generalized© Jones, or located& Bartlett in most Learning, of the tissues LLC in conditionNOT FOR because SALE the patientOR DISTRIBUTION is unaware of having it. one area.NOT The FOR term SALE “diffuse” OR is alsoDISTRIBUTION sometimes used Sometimes the medical/dental history will provide clues (Fig. 1.14). to the etiology and history of the problem through nota- ● “Single lesion” (Fig. 1.13) or “multiple lesions” tions about chronic conditions such as diabetes, recent (Fig. 1.15) further define the distribution. illnesses, and medications. The patient should be asked  If there are multiple lesions, are they distinct or © Jones & Bartlettabout pain Learning, in the area or LLC feelings of paresthesia (numb©- Jones &discrete Bartlett and Learning,separate, or LLCare they coalescing or NOT FOR SALEness, tingling, OR DISTRIBUTION or other altered sensations). If there is pain,NOT FOR growingSALE togetherOR DISTRIBUTION and becoming one large lesion additional information such as the level of pain, whether (Fig. 1.16)? it is sharp or dull, constant or occasional, can help begin the process of determining what is happening. Box 1.5 discusses effective use of follow-up questions. ■ Location—An accurate© Jones description & Bartlett of the location Learning, of the LLC © Jones & Bartlett Learning, LLC lesion must be recorded.NOT Some FOR dental SALE charts OR will DISTRIBUTION have a NOT FOR SALE OR DISTRIBUTION diagrammatic representation of the areas in the mouth where a facsimile of the lesion can be drawn. If not, the location of the lesion needs to be described using appropriate terminology. Use terms such as inferior, superior, lateral,© Jones medial, & anterior, Bartlett posterior, Learning, distal, LLCand mesial to © Jones & Bartlett Learning, LLC denoteNOT location. FOR SALE Always ORtry to DISTRIBUTION pick a fixed point of refer- NOT FOR SALE OR DISTRIBUTION ence close to the lesion to start the location description, such as adjacent to tooth #29 on the buccal mucosa or located in the middle one-third of the tongue or 2 mm left of the midline. Use a probe to measure distances © Jones & Bartlettfrom the point Learning, of reference LLC to the lesion and the size of© JonesFIGURE & 1.13. BartlettLocalized. Learning,This nodule is confined LLC to the gingival tissues NOT FOR SALEthe lesion OR itself. DISTRIBUTION NOTbetween FOR the SALE canine andOR the DISTRIBUTION premolar.

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC FIGURENOT 1.14. FORGeneralized SALE with irregular OR DISTRIBUTION margins. This white lesion of FIGURE 1.16. NOTCoalescing FOR lesions. SALE This recurrent OR herpesDISTRIBUTION labialis lesion lichen planus (see Chapter 13) called Wickham striae covers the entire consists of separate vesicles that have begun to coalesce or grow right and left buccal mucosal surfaces with an irregular lacy pattern. together.

● Margins define the extent of the lesion and are either “well © Jones & Bartlettdefined” Learning, orcircumscribed LLC (Fig. 1.17) or “poorly defined”© Jones & Bartlett Learning, LLC NOT FOR SALEand vague.OR DISTRIBUTION Poorly defined margins are difficult to deterNOT- FOR SALE OR DISTRIBUTION mine, and the dental hygienist may not be sure where the lesion ends and where normal tissue begins (Fig. 1.18). ● Well-defined margins may be “regular” (Fig. 1.17) or “irregular” (Fig. 1.24) in shape. ■ Size and shape—Note© theJones general & shape Bartlett and measure Learning, the LLC © Jones & Bartlett Learning, LLC size of the lesion withNOT a probe. FOR Measure SALE the OR diameter DISTRIBUTION of NOT FOR SALE OR DISTRIBUTION round lesions and the width and length of square, rect- angular, and oval lesions. When writing the numbers for length and width, the width will come first; for example, a 5-inch by 7-inch picture frame will be 5 inches wide and 7 ©inches Jones long. &The Bartlett size of aLearning, very large lesion LLC might have © Jones & Bartlett Learning, LLC to be related to the area it covers, such as the entire left NOT FOR SALE OR DISTRIBUTION FIGURE 1.17. NOTWell circumscribed FOR SALE with a well-defined OR DISTRIBUTION regular margin. lateral border of the tongue from the tip to the circumval- This granular cell tumor is well defined within the tissues. Note the yellow late papilla. If the lesion has any height, this must be noted papules called Fordyce granules (see Chapter 13). (Courtesy of the U.S. also. Height is listed after the length of the lesion. Department of Veteran’s Affairs.) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

FIGURE 1.18. Poorly defined margin. Sun exposure has caused actinic keratosis or cheilitis on the lower lip. Some of the central areas are obvious, but it is difficult to determine exactly where the lesion ends, as © Jones &FIGURE Bartlett 1.15. Multiple Learning, lesions. The LLC hard palate is covered with multiple© Jonesit extends & away Bartlett from the centralLearning, area. (Courtesy LLC of the U.S. Department NOT FORdiscrete SALE lesions OR along DISTRIBUTION with some that appear to coalesce. NOTof FOR Veteran’s SALE Affairs.) OR DISTRIBUTION

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC FIGURENOT 1.19. FORMacule. SALEThis flat lesion OR is DISTRIBUTION differentiated from the sur- NOT FOR SALE OR DISTRIBUTION rounding tissue by color alone. FIGURE 1.21. Bulla. This large bulla formed as a result of a contact thermal burn. ● A flat lesion differentiated from the surrounding tissue © Jones & Bartlettby color Learning,alone is called LLC a macule (Fig. 1.19) if it is less© Jones ● Depressed & Bartlett lesions Learning, can either LLC be ulcers (Fig. 1.26), NOT FOR SALEthan OR1 cm DISTRIBUTION in diameter and a patch if it is more thanNOT FORwhich SALE extend OR through DISTRIBUTION the epithelium into the der- 1 cm. A patch may also describe an area that has a dif- mis, or erosions (Fig. 1.27), which do not extend ferent surface texture with or without a color change. through the epithelium. Erosions can also be called ● An elevated lesion may be a vesicle (Fig. 1.20) if it abrasions. is 0.5 cm or less and is filled with a clear fluid. If it is larger ● Two other terms are used to describe the general than 0.5 cm, it would© Jones be called & a bullaBartlett (Fig. 1.21). Learning, LLCdirection of growth of ©a lesion.Jones Exophytic & Bartlett lesions Learning, LLC ● A pustule is a raisedNOT lesion FOR filled SALE with OR pus DISTRIBUTIONorpuru- grow outward from the NOTsurface FOR of the SALE tissue likeOR the DISTRIBUTION lent exudate. fibromas in Figures 1.22 and 1.23, andendophytic ● A raised lesion with no fluid inside is called apap - lesions grow into the surrounding tissues and pres- ule (Fig. 1.22) if it is less than 5 mm in diameter; a ent as palpable masses with or without any noticeable slightly larger, less than 2-cm, raised lesion is called swelling. ©a noduleJones (Fig. & Bartlett 1.23), and Learning, anything larger LLC is called a ■ Color—Abnormal© Jones areas & Bartlett may be the Learning, same color LLCas the NOTtumor FOR. SALE OR DISTRIBUTION surroundingNOT tissues FOR or theySALE could OR be white,DISTRIBUTION erythematic ● If the area is broad and slightly raised, has a flat top, (red), yellow, or pigmented. and looks pasted on, it is called a plaque (Fig. 1.24). ● Normal color includes all variations of normal includ- ● A growth can be attached to the surrounding tissues ing normal physiologic pigmentations (Fig. 1.28). by a broad or sessile base, as illustrated by the fibro- ● White lesions that cannot be wiped off (Fig. 1.24) usu- © Jones & Bartlettmas in Figures Learning, 1.22 and LLC 1.23 or by a stalk (referred to© Jonesally & involveBartlett excess Learning, keratin in theLLC tissues, making them NOT FOR SALEas pedunculated OR DISTRIBUTION) (Fig. 1.25). NOT FORmore SALE opaque, OR like DISTRIBUTION a callus on the hand.

FIGURE 1.20. Vesicle. This recurrent herpes labialis lesion (see Chapter 10) © Jones &is inBartlett the vesicular Learning, stage. The outlines LLC of the smaller vesicles that have © JonesFIGURE & 1.22. BartlettPapule. This Learning, small fibroma LLC(see Chapter 16) is the appro- NOT FORcoalesced SALE into OR this DISTRIBUTION larger lesion are still visible. NOTpriate FOR size SALE to be described OR asDISTRIBUTION a papule.

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC FIGURE 1.23. Nodule. This NOTlarger fibroma FOR on SALE the buccal OR mucosa DISTRIBUTION is NOT FOR SALE OR DISTRIBUTION considered to be a nodule. B FIGURE 1.25. A, B. Pedunculated. The small pink papule apical to 24 and 25 (A) is attached to the underlying tissue by a thin stalk as ● Erythematic areas (Fig. 1.29) usually indicate thinning seen when the tissue is lifted with the tip of an explorer (B). (Courtesy of of the epithelium allowing the more vascular subepi- Dr. Harvey Kessler.) ©thelial Jones or submucosal & Bartlett tissues Learning, to be seen, LLC or erythema © Jones & Bartlett Learning, LLC NOTmay indicate FOR anSALE increased OR blood DISTRIBUTION flow into the area due NOT FOR SALE OR DISTRIBUTION to an inflammatory reaction (see Chapter 3). source) pigments. Black macules that are adjacent ● Yellow can indicate the presence of purulent exudate to teeth with amalgam restorations are very often or adipose tissue (fat) (Fig. 1.30). caused by pigments from the amalgam, accidentally ● Other pigmentations include brown, black, and blue. introduced into the soft tissues, leaching into the © Jones & BartlettThese colorsLearning, can represent LLC either endogenous (from© Jonessurrounding & Bartlett tissue, Learning, resulting LLCin an amalgam tattoo NOT FOR SALEwithin OR the DISTRIBUTION body) or exogenous (from an outsideNOT FOR(Fig. SALE 1.31). SmallerOR DISTRIBUTION black macules in the roof of the

FIGURE 1.24. Plaque. The slightly raised and flat configuration of this FIGURE 1.26. Ulcer. These ulcers exhibit the classic features associated © Jones &white Bartlett lichen planus Learning, lesion covering LLC a relatively broad area is indicative of© Joneswith this & type Bartlett of lesion, a Learning,central depressed LLC area covered by a white NOT FORa SALE plaque. Also OR note DISTRIBUTION the well-defined irregular margin. NOTpseudomembrane FOR SALE and OR surrounded DISTRIBUTION by an erythematic ring.

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC FIGURENOT 1.27. FORErosion. SALEJust the surface OR epitheliumDISTRIBUTION has been destroyed, NOT FOR SALE OR DISTRIBUTION leaving a diffuse area of erythema in these erosive lichen planus lesions on the lower lip.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOTFIGURE FOR 1.30. SALEYellow. OR Xanthelasma, DISTRIBUTION a yellowish plaque located around the eye lids, is associated with high levels of cholesterol.

mouth, gingiva, or lips can be caused by a pencil lead © Jones & Bartlett Learning, LLCbeing stabbed into the tissues.© Jones This is& usuallyBartlett acciden Learning,- LLC NOT FOR SALE OR DISTRIBUTIONtal and occurs when childrenNOT run FOR or play SALE with a OR pencil DISTRIBUTION in their mouth. The patient may or may not remember the incident. Another cause of a black macule is melanoma, a cancer of the pigment-producing cells or melanocytes (see Fig. 14.14A and B in Chapter 14). © Jones & Bartlett Learning, LLC Melanoma© Jones is very &serious Bartlett and very Learning, difficult LLCto treat. NOT FOR SALE OR DISTRIBUTION Blue lesionsNOT areFOR most SALE likely ORvascular, DISTRIBUTION such as labial varicosities (Fig. 1.32), but they can also be intraoral nevi (Fig. 1.33) or melanomas. Brown lesions usually FIGURE 1.28. Physiologic pigmentation. Normal melanin pigmentation contain melanin pigments and can be associated with of the gingival tissues. normal physiologic pigmentation, an intraoral nevus, © Jones & Bartlett Learning, LLC © Jonesa &melanotic Bartlett macule Learning, (Fig. 1.19), LLC or a melanoma. Any black, blue, or brown pigmented lesion is cause for NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

FIGURE 1.31. Black or blue/black lesion. An amalgam tattoo on the FIGURE 1.29. Erythema. This red lesion with poorly defined margins floor of the mouth. The amalgam was accidentally introduced into the © Jones &was Bartlett found to be Learning,an invasive squamous LLC cell carcinoma. (Courtesy of the© Jonessoft tissues & Bartlettwhen an amalgam Learning, restoration wasLLC being placed. (Courtesy NOT FORU.S. SALE Department OR of DISTRIBUTION Veteran’s Affairs.) NOTof FOR Dr. Peter SALE Jacobsen.) OR DISTRIBUTION

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC FIGURENOT 1.32. FORLabial varices. SALE This ORolder gentlemanDISTRIBUTION has a bluish vascular FIGURE 1.34. NOTSmooth FORsurface texture.SALE The OR swelling DISTRIBUTION on the floor of the lesion on the upper lip. mouth depicts a normal smooth surface texture.

concern, and an explanation for its presence should be ● A smooth surface texture is usually found when there © Jones & Bartlettdetermined. Learning, The options LLC for follow-up on lesions such© Jonesis & submucosal Bartlett swellingLearning, and theLLC surface of the lesion NOT FOR SALEas these OR are DISTRIBUTION discussed in Chapters 5 and 14. NOT FORis covered SALE by OR normal DISTRIBUTION mucosal epithelium (Fig. 1.34). ■ Consistency—Consistency refers to how something ● Rough surface textures are described by how they feels when pressed on or between two surfaces such feel and how they look. Common terms to describe as between your thumb and forefinger or between roughness include the following: your finger and the hard palate. Students and clinicians  Papillary, consisting of finger-like projections often confuse the terms© Jones used for & consistency Bartlett Learning,and those LLC (Fig. 1.35) © Jones & Bartlett Learning, LLC  used for surface texture.NOT TryFOR to rememberSALE OR consistency DISTRIBUTION Corrugated, rippled,NOT or washboard-like FOR SALE (Fig. OR 1.36) DISTRIBUTION is determined by how the area feels when pressed, not  Fissured, consisting of many deep crevices what it feels like when a fingertip is rubbed across its (Fig. 1.37) surface. Most of the case studies in this book provide a  Crusted or covered with a scab may also be used description of consistency, since consistency cannot be to describe perioral lesions (Fig. 1.16). The intraoral seen.© Jones & Bartlett Learning, LLC counterpart© Jones of a& crust Bartlett is a pseudomembrane Learning, LLC or ● NOTThe consistencyFOR SALE of softOR tissue DISTRIBUTION abnormalities is often falseNOT membrane FOR that SALE covers OR the DISTRIBUTIONsurface of a lesion soft or normal feeling. and can be wiped off (Fig. 1.38). ● Indurated soft tissue lesions, such as an inflamed lymph node, feel quite hard. Describing Radiographic Findings ● is used to describe a fluid-filled lesion that Fluctuant Radiographs are an integral part of most dental examina- moves fluid from one area to another when the lesion © Jones & Bartlett Learning, LLC © Jonestions. &Diagnostic Bartlett radiographs Learning, may LLC be exposed as part of is pressed. NOT FOR SALE OR DISTRIBUTION NOTa FORroutine SALE dental ORexamination, DISTRIBUTION or they may be exposed to ■ Surface texture—The surface texture of an intraoral lesion is determined by how it feels when the pad of a fingertip is run across it and what it looks like. “Smooth” and “rough” are the main descriptive categories. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

FIGURE 1.35. Papillary. This lesion is made up of many finger-like pro- © Jones &FIGURE Bartlett 1.33. Nevus. Learning, Blue nevus LLCof the hard palate. (Courtesy of Mar- © Jonesjections &as itsBartlett name papilloma Learning, suggests. (Courtesy LLC of the U.S. Depart- NOT FORquette SALE University OR School DISTRIBUTION of Dentistry.) NOTment FOR of Veteran’s SALE Affairs.) OR DISTRIBUTION

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© Jones & Bartlett Learning, LLC © JonesAPPLICATION & Bartlett Learning,1.2. Application LLC to Practice NOT FOR SALE OR DISTRIBUTION NOT FORClinical SALE Description OR DISTRIBUTION of Oral and Perioral Lesions Refer to Figure 1.34 for an image of the soft tissue description developed in this section. © Jones & Bartlett Learning, LLCHistory: The patient was unaware© Jones of this lesion & Bartlett until 2 days Learning, LLC ago. She reports no history of trauma, and there are no sig- NOT FOR SALE OR DISTRIBUTIONnificant findings on the medicalNOT or dentalFOR histories. SALE OR DISTRIBUTION ■ Location: Floor of the mouth (FOM) 5 mm to the left of the lingual frenum at the level of the sublingual caruncle ■ Distribution and definition: Single, localized, and well circumscribed © Jones & Bartlett Learning, LLC ■ Size and© Jonesshape: Round & Bartlett nodule 18 Learning, mm in diameter LLC FIGURE 1.36. Corrugated. The white corrugated lesions extending from NOT FOR SALE OR DISTRIBUTION 10 mmNOT in height, FOR sessile SALE base OR DISTRIBUTION the buccal mucosa through the mucobuccal fold up into the attached ■ Color: Slightly bluish with an erythematic ring around the gingival are characteristic of those caused by spit tobacco use. base ■ Consistency: Soft and fluctuant ■ Surface texture: Smooth © Jones & Bartlett Learning, LLC © JonesDescription: & Bartlett Single, well-circumscribed,Learning, LLC bluish nodule approxi- NOT FOR SALE OR DISTRIBUTION NOT FORmately SALE18 mm in OR diameter DISTRIBUTION and 10 mm in height, surrounded by an erythematic ring, soft, fluctuant with a smooth surface and sessile base, located on the FOM, 5 mm left of lingual frenum level with sublingual caruncle. Patient reports she became aware of the swelling 2 days ago, no report of trauma, and no other significant findings on the medical or dental histories. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

obtain more information about an abnormality discovered through observation or palpation of the intraoral or perioral tissues. Radiographic abnormalities are often discovered © Jones & Bartlett Learning, LLC by accident© when Jones there & are Bartlett no clinically Learning, observable LLC signs NOT FOR SALE OR DISTRIBUTION or symptoms.NOT A briefFOR description SALE OR of DISTRIBUTIONradiographic findings should be recorded in the patient’s record in case the FIGURE 1.37. Fissured. This is a classic example of a fissured tongue. radiographs become misplaced. The features that should be The deep fissures can collect food debris and provide a perfect environ- ment for the growth of dental biofilm. The fissuring is not usually seen in described include the following: children and worsens as the individual ages. ■ History—The patient should be asked whether he or © Jones & Bartlett Learning, LLC © Jonesshe &is awareBartlett of the Learning, area in the radiographLLC or not. If the NOT FOR SALE OR DISTRIBUTION NOT FORpatient SALE is aware, OR ask DISTRIBUTION what he or she was told it was, how long it has been present, and if there are any symptoms associated with it. The most common symptoms associated with bone lesions are pain and paresthesia. Very often, there is no history, and the dental team will have to © Jones & Bartlett Learning, LLCstart the process of determining© Jones the cause & Bartlettof the lesion. Learning, LLC NOT FOR SALE OR DISTRIBUTION ■ Location and size—DeterminingNOT FOR the SALElocation OR of DISTRIBUTIONa radiographic finding is often made difficult by the radiographic technique used for exposing the film. Radiographs taken with excessive or inadequate vertical or horizontal angulation will not reflect the true location © Jones & Bartlett Learning, LLC of the anomaly.© Jones Panoramic & Bartlett radiographs Learning, may also LLCdistort NOT FOR SALE OR DISTRIBUTION the true NOTposition FOR of an SALE anomaly. OR Care DISTRIBUTION must be taken to use every means to accurately locate the abnormality. In most instances when there is doubt about the location, multiple radiographs will be taken from different aspects FIGURE 1.38. Pseudomembrane. The white surface membrane char- and with different angulations to more accurately place © Jones &acteristic Bartlett of pseudomembranous Learning, candidiasisLLC leaves a sore erythematic © Jonesthe &anomaly. Bartlett Size Learning,can be recorded LLC in millimeters or cen- NOT FORarea SALE behind OR when DISTRIBUTIONit is wiped off with gauze. NOT FORtimeters SALE and, ifOR large, DISTRIBUTION relative to the structures involved.

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■ Distribution—Distribution describes the number of anom- © Jones & Bartlettalies and how Learning, they are positioned LLC within the hard tissues.© Jones & Bartlett Learning, LLC NOT FOR SALE ● “Single” OR is DISTRIBUTION used to describe one lesion. NOT FOR SALE OR DISTRIBUTION ● More than one lesion is described as “multiple lesions.”  “Localized” or “focal” describes a clustered group of lesions.  “Generalized” or “diffuse” describes multiple findings in a large area© Jones of bone. & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■ Radiographic features—SpecificNOT FOR terms SALE are usedOR to DISTRIBUTION describe NOT FOR SALE OR DISTRIBUTION radiographic findings. These terms include the following: ● Whether a radiographic anomaly is radiopaque (whiter than the normal radiographic appearance of the bone) as in Figure 1.39, radiolucent (darker than ©the Jones normal &radiographic Bartlett Learning,appearance of LLC bone) as in © Jones & Bartlett Learning, LLC NOTFigure FOR1.40 or SALE mixed OR(consisting DISTRIBUTION of both radiopaque NOT FOR SALE OR DISTRIBUTION and radiolucent areas) as in Figure 1.41 will help to exclude many conditions from a list of potential diagnoses. The radicular cyst (see Chapter 20) seen © Jones & Bartlettin Figure Learning, 1.40 would notLLC be considered as a possible© Jones & Bartlett Learning, LLC diagnosis if the spherical lesion at the apex of a tooth NOT FOR SALEwere OR radiopaque. DISTRIBUTION Condensing osteitis (see ChapterNOT FOR SALE OR DISTRIBUTION 19) would be much more likely because its normal presentation is radiopaque (Fig. 1.39), while that of a radicular cyst is radiolucent. ● Many lesions present© Jones as a single & Bartlett or unilocular Learning, radi- LLC © Jones & Bartlett Learning, LLC opaque or radiolucent area, while others look as if FIGURE 1.40. Radiolucent. Note the well-defined spherical radiolucent there are compartmentsNOT FOR within SALE the lesion. OR ADISTRIBUTION radio- area apical to the canine. NOT FOR SALE OR DISTRIBUTION lucent lesion made up of these compartments is said to be multilocular, and they are often described as where the abnormal hard tissue ends and the normal having a “soap bubble” appearance (Fig. 1.42). tissue begins (Fig. 1.44). Poorly defined margins are ● considered to be more indicative of an aggressive or ©It Jonesis important & Bartlett to determine Learning, the clarity LLC of the mar- © Jones & Bartlett Learning, LLC gins of a radiographic anomaly. Lesions with clearly malignant condition. NOTdefined FOR or SALEwell-demarcated OR DISTRIBUTION margins (Fig. 1.43) are NOT FOR SALE OR DISTRIBUTION more likely to be benign and less aggressive entities. Indistinct margins should be described as poorly defined or “irregular.” Poorly defined margins will appear fuzzy or ragged, and it is difficult to determine © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

FIGURE 1.39. Radiopaque. Note the well-defined radiopaque area of © Jones &condensing Bartlett osteitis Learning, at the apex of LLCthe root of the second premolar and © JonesFIGURE & 1.41. BartlettMixed. This Learning, lesion exhibits both LLC radiolucent and radi- NOT FORfirst SALE molar. OR DISTRIBUTION NOTopaque FOR characteristics. SALE OR DISTRIBUTION

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORFIGURE SALE 1.42. ORMultilocular. DISTRIBUTION The multilocular radiolucent lesions in this NOT FOR SALE OR DISTRIBUTION radiograph are associated with a connective tissue condition called FIGURE 1.44. Poorly defined margins. Note the radiopaque area sur- cherubism. rounding the first and second molars and the slightly opaque areas that seem to be extending toward the anterior region. It is difficult to determine the extent of this osteogenic sarcoma (bone cancer) because of the poorly © Jones & Bartlett Learning, LLCdefined borders. (Courtesy of the U.S.© Department Jones of& Veteran’s Bartlett Affairs.) Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ● The appearance of the surrounding tissues is also important, and close attention must be paid to this area.  If the abnormality involves the roots of any teeth, it © Jones & Bartlett Learning, LLC is important© Jones to determine & Bartlett if it isLearning, causing resorption LLC or destruction of the roots (Fig. 1.45) or causing NOT FOR SALE OR DISTRIBUTION themNOT to move FOR out SALEof the way OR through DISTRIBUTION convergence (movement toward each other) or divergence (movement away from each other) (Fig. 1.46).

FIGURE 1.43. Well-defined margins. The odontoma (see Chapter 18) FIGURE 1.45. Root resorption. The distal root of the mandibular second is an example of a lesion that has well-defined radiographic margins as molar has been severely resorbed by the pathologic lesion surrounding © Jones &well Bartlett as mixed radiolucent Learning, and opaque LLC elements. © Jonesthe unerupted & Bartlett third molar. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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FIGURE 1.46. Divergence. This radiolucent lesion has caused the canine and lateral roots to spread apart.© Jones & Bartlett Learning, LLCFIGURE 1.48. Cortical bone destruction.© Jones The central & giant Bartlett cell granu- Learning, LLC NOT FOR SALE OR DISTRIBUTIONloma (see Chapter 17) pictured in thisNOT radiograph FOR has SALE eroded through OR DISTRIBUTION the cortical bone in the edentulous mandibular area. (Courtesy of the  Changes in the periodontal ligament space such as U.S. Department of Veteran’s Affairs.) widening (Fig. 1.47) or loss of the space should be noted.  © JonesThe lamina & Bartlett dura should Learning, be observed LLC to determine  If the© corticalJones bone & Bartlett can be seen, Learning, it should be LLC noted whether there have been any changes in its struc- NOT FOR SALE OR DISTRIBUTION if thereNOT have FOR been SALE any changes, OR DISTRIBUTION specifically if the ture or if it is missing altogether. lesion has been able to erode through the cortical bone (Fig. 1.48) or if there has been expansion of the bone in the surrounding area (Fig. 1.49).

FIGURE© 1.47. JonesWidening & Bartlett of the periodontal Learning, ligament space. LLC This radio- © Jones & Bartlett Learning, LLC graphNOT is of a 34-year-oldFOR SALE woman whoOR was DISTRIBUTION incorrectly treated for peri- NOT FOR SALE OR DISTRIBUTION odontal disease. Note the widened periodontal ligament space around the first molar. There is a separation between the first and second molar, FIGURE 1.49. Bone expansion. This is an occlusal view of an osteo- and the interproximal alveolar bone has a mottled atypical appearance genic sarcoma (see Chapter 17). Arrows point to the sunburst pattern compared to what would be expected. A biopsy of the area between the of abnormal bone and expansion that are characteristic of this tumor. © Jones &two Bartlett molars found Learning, osteogenic carcinoma. LLC (Courtesy of Dr. John W. Preece.)© Jones(Courtesy & of Bartlett the U.S. Department Learning, of Veteran’s LLC Affairs.) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© Jones & APPLICATIONBartlett Learning, 1.3. LLCApplication to Practice© Jones & Bartlett Learning, LLC NOT FOR SALERadiographic OR DISTRIBUTION Descriptions NOT FOR ■ Size: SALERound, approximately OR DISTRIBUTION 1 cm in diameter (in the original film) The panoramic radiograph in Figure 1.50 depicts the radi- ■ Distribution: Single opaque object used as the example for developing the follow- ■ Margins: Well defined ing radiographic description. ■ Opacity: Radiopaque History: The patient is© unaware Jones of this & Bartlettfinding and Learning,knows of no LLCDescription: A single, well-defined,© Jones 1-cm diameter, & Bartlett round radi Learning,- LLC symptoms associatedNOT with it. FOR SALE OR DISTRIBUTIONopaque object located slightly NOTinferior FORto the SALEleft condyloid OR DISTRIBUTION ■ Location: Left ramus of the mandible just inferior to the process. The patient is unaware of the lesion and reports no condyloid process symptoms.

FIGURE 1.50. Radiopaque object. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Determining a Diagnosis 4. Rank the remaining possible causes according to the probability they are the causative agent. Creating a differential diagnosis for a particular lesion can 5. Decide what additional information might be neces- © Jones &be Bartlett very interesting Learning, and educational. LLC Exploring the outermost© Jones & Bartlett Learning, LLC boundaries of the scope of dental hygiene practice can pro- sary to eliminate more of the possibilities, such as NOT FORvide SALE intellectual OR DISTRIBUTION stimulation and create career satisfaction.NOT FORblood SALE tests, ORbiopsy DISTRIBUTION, diagnostic radiographs, cultures of oral microbes, and medical consultations. Differential Diagnosis The clinician may decide to treat the lesion as the manifestation of the most likely cause as the best course A differential diagnosis is a listing of the probable causes of of action (therapeutic diagnosis). For example, if the a particular disease manifestation© Jones &or Bartlett group of manifestaLearning,- LLCmost likely cause of a lesion is© a Jones fungal infection, & Bartlett and itLearning, is LLC tions. There is a processNOT involved FOR withSALE creating OR a DISTRIBUTIONdifferen- treated for 10 days with a topicalNOT antifungalFOR SALE medication OR DISTRIBUTION tial diagnosis, and it should be followed more or less every resolving the lesion, it was most likely a fungal infection. time something is seen that cannot be identified. The steps A second possibility is that it resolved on its own, and to creating a differential diagnosis are as follows: no one will ever be sure of the actual cause. If it does not 1. Describe the abnormality in clinical terms. resolve, more specific diagnostic procedures are appro- 2. ©Determine Jones a& list Bartlett of diseases/conditions Learning, LLC that present priate. It is© not Jones within &the Bartlett scope of Learning,practice of a LLCdental NOTwith similar FOR manifestations. SALE OR DISTRIBUTION hygienist toNOT order FOR any ofSALE these ORtests DISTRIBUTIONor to recommend 3. Eliminate some of the possible causes already listed by some therapies, but it is appropriate to be aware of what adding other factors that could be involved with the the options are and thus be able to have some input as a abnormality (chronic health condition, medications, valuable member of the dental team. If a definitive diag- patient age, and whether the patient has any other nosis is not determined by the additional information © Jones & Bartlettmanifestations Learning, that are LLC inconsistent with any of the© Jonesobtained, & Bartlett then the listLearning, of conditions LLC that remains is the NOT FOR SALElisted OR possibilities). DISTRIBUTION NOTdifferential FOR SALE diagnosis. OR DISTRIBUTION

9781284209372_CH01_001_025.indd 20 26/03/20 5:08 PM CHAPTER 1 Introduction to General and Oral Pathology 21

© Jones & APPLICATIONBartlett Learning, 1.4. LLCApplication to Practice© Jones & Bartlett Learning, LLC NOT FOR SALEHow to OR Create DISTRIBUTION a Differential Diagnosis NOT FORthere SALE would OR be noDISTRIBUTION pain associated with a chancre, so this can also be eliminated. The following is a simple example of how to create a differen- ■ Erythema multiforme is an immune response that tial diagnosis. The possible causes listed in the differential presents with skin and mucous membrane lesions. diagnosis are described in detail in Chapter 11. Refer to this The absence of skin lesions and the fact that this is a chapter if necessary for© aJones more complete & Bartlett description Learning, of why a LLC solitary lesion probably indicate© Jones that this& Bartlett disorder can Learning, LLC condition is eliminated from the list of possibilities. Refer to NOT FOR SALE OR DISTRIBUTIONbe eliminated. NOT FOR SALE OR DISTRIBUTION Figure 1.51 for this application. ■ Traumatic ulcers look like this lesion, and they are often found on the lip, tongue, cheeks, and other areas that are subject to frequent trauma. This diagnosis is highly likely. ■ Recurrent aphthous ulcers look like this lesion and © Jones & Bartlett Learning, LLC present© Joneson the moveable & Bartlett mucosa; Learning, in addition, LLCthey NOT FOR SALE OR DISTRIBUTION can beNOT precipitated FOR bySALE trauma OR to the DISTRIBUTION tissues. It is not known whether this patient has had this type of ulcer before. Without more information, this diagnosis must also be considered likely. 4. A ranking of the remaining possibilities is difficult in this © Jones & Bartlett Learning, LLC © Jonescase & becauseBartlett there Learning, is an equal LLC probability it could be either one. In this case, more information is needed. It NOT FOR SALE OR DISTRIBUTION NOT FORis necessary SALE toOR ask DISTRIBUTION a few more questions, such as the following: ■ When did you notice the ulcer? ● Answer: About 2 days ago. FIGURE 1.51. Differential diagnosis. ■ Have you ever had ulcers like this on your lip or in your © Jones & Bartlett Learning, LLC mouth before? © Jones & Bartlett Learning, LLC 1. Clinical descriptionNOT and history:FOR Single,SALE well-defined OR DISTRIBUTION ulcer ● Answer: I had one on NOTmy gums FOR after I SALEhit myself OR with DISTRIBUTION covered by a white pseudomembrane and surrounded by a toothbrush. an erythematic ring; the ulcer is oval, approximately 4 mm ■ Do you remember doing anything to cause the ulcer? × 3 mm, firm and slightly rough to the touch, and located ● Answer: Yeah, I bit my lip! on the lower labial mucosa adjacent to tooth #27 at the 5. These questions have clarified the circumstances that oc- margin of the labial mucosa and the extraoral lip tissue. curred prior to the development of the ulcer. The follow- ©The Jones patient &is Bartlett10 years old Learning, and has no significant LLC medi- © Jones & Bartlett Learning, LLC ing must be considered before eliminating either of the cal or dental findings other than the report of slight pain NOT FOR SALE OR DISTRIBUTION possibilities.NOT FOR SALE OR DISTRIBUTION in the lip. ■ Only one other ulcer located on the attached gingival 2. The following are considered as part of the differential surface occurred previous to this ulcer, and that ulcer diagnosis: was also associated with trauma. ■ Reiter syndrome (Chapter 11) ■ Recurrent aphthous ulcers do not normally affect the © Jones & Bartlett■ Syphilis Learning, (Chapter 11) LLC © Jones &attached Bartlett gingiva, Learning, indicating that LLC the previous ulcer was ■ Erythema multiforme (Chapter 11) probably not recurrent aphthous. NOT FOR SALE■ TraumaticOR DISTRIBUTION ulcer (Chapter 11) NOT FOR■ Causal SALE relationships OR DISTRIBUTION are important, and in this case, ■ Recurrent aphthous ulcer (Chapter 11) the patient has supplied the cause. 3. Rationale for excluding some elements of the differential 6. The only possible way to obtain a definitive diagnosis diagnosis of this lesion would be to biopsy the lesion, which may ■ Reiter syndrome usually occurs in males in their 30s not provide anything more than to describe the lesion as and normally ©manifests Jones with & Bartlettconcurrent generalizedLearning, LLCcontaining inflammatory cells,© Joneswhich would & Bartlettbe likely in eiLearning,- LLC arthritis. This youngNOT man FOR is 10 SALE and reports OR noDISTRIBUTION signifi- ther case. The cause-and-effectNOT relationship FOR SALE between OR the DISTRIBUTION cant medical findings such as arthritis. Thus, Reiter trauma of biting the lip and the appearance of the ulcer syndrome can be eliminated as a possibility. and the fact that there is no previous report of aphthous ■ Primary syphilis is a sexually transmitted disease that ulcers support the diagnosis of a traumatic ulcer. The clini- presents with a large ulcer-like chancre at the initial cal manifestation of the ulcer would be treated the same © Jonespoint of &contact. Bartlett This patient Learning, is most likely LLC not sexually way for either© Jones diagnosis. & BartlettThe only consideration Learning, would LLC be active at age 10, but the possibility of sexual abuse to alert the patient of the possibility that more ulcers oc- NOTwould FOR have SALE to be ruledOR DISTRIBUTIONout. The clinical appearance curring inNOT the absence FOR ofSALE trauma ORmight DISTRIBUTION indicate recurrent of this lesion is much too small to be a chancre, and aphthous ulcers.

9781284209372_CH01_001_025.indd 21 26/03/20 5:08 PM 22 PART I General Pathology Definitive Diagnosis © Jones & Bartlett Learning, LLC © JonesSummary & Bartlett Learning, LLC NOT FORA SALE definitive OR diagnosisDISTRIBUTION is determined when all of the susNOT- FOR ■ The SALEconcept ORof health DISTRIBUTION comprises a wide range of physi- pected causes on the list except one have been eliminated. cal, emotional, and spiritual components. That one cause is the definitive diagnosis. It would be dif- ■ Individuals are being encouraged to take charge of their ficult for the dental hygienist to repeat this process every lives and establish a sense of personal responsibility for time an abnormal area in or around the oral cavity was dis- their own health. covered. Fortunately, such© Jones a lengthy & Bartlettprocess is notLearning, neces- LLC ■ Patients are expected to take© Jones a dynamic & Bartlett role in their Learning, LLC sary. Many of the mostNOT common FOR abnormalities SALE OR have DISTRIBUTION such health care. Health care providersNOT FOR are expected SALE not OR only DISTRIBUTION distinguishing characteristics that unlikely causes can be to provide treatment but also to facilitate this new active eliminated solely through observation of the abnormality. role by helping to direct and educate the patient in ways Some of the conditions discussed in this book are atypical, of attaining total body wellness. or variations of normal, and not pathologic. By observing ■ Oral health is an integral part of total body health, and these© conditions Jones &clinically, Bartlett the dentalLearning, hygienist LLC will become the dental© teamJones is responsible & Bartlett for Learning,helping the patientLLC very NOTfamiliar FOR with themSALE and OR will DISTRIBUTIONknow immediately if there achieve andNOT maintain FOR good SALE oral ORhealth. DISTRIBUTION is something else happening. Conditions such as leuko- ■ Oral medicine is an emerging dental speciality con- edema and tori can be clinically diagnosed because they are cerned with treating medically complex patients from a very common and have such clear clinical manifestations “whole body” perspective. there is no doubt about what they are. Some other patho- ■ The oral cancer screening examination is an important © Jones &logic Bartlett conditions Learning, such as caries LLC can be diagnosed from their© Joneselement & Bartlett in determining Learning, the oral LLC health of the patient. NOT FORcharacteristic SALE OR radiographicDISTRIBUTION appearance. The danger arisesNOT FOROral SALEcancers ORare usually DISTRIBUTION diagnosed in the late stages, when the dental team starts assuming everything seen is and early diagnosis and treatment will decrease the a variation of normal. Often, there is concern the patient incidence of disfiguring surgery and increase cancer might be subjected to undue stress about something that survival rates. is most likely benign. An effort must be made to determine ■ It is necessary to write an accurate and complete descrip- the cause of all suspicious© Jones areas identified. & Bartlett In Learning,many cases, LLCtion of abnormal clinical or© radiographic Jones & findingsBartlett in Learning,the LLC this will require a visitNOT to an FORoral surgeon SALE for OR a biopsy; DISTRIBUTION or patient’s dental record so NOTthe proper FOR follow-up SALE canOR be DISTRIBUTION the biopsy, exfoliative cytology, or brush biopsy may be accomplished. performed in the general dental office. Some patients may ■ An exciting aspect of oral pathology is first creating a be unduly alarmed by a referral for a biopsy of what turns differential diagnosis and then determining a definitive out to be an amalgam tattoo, but the alternative diagnosis diagnosis based on the elimination of improbable ele- of a ©melanoma Jones must& Bartlett be considered Learning, until ruled LLC out. Many ments of ©the Jones differential & Bartlett diagnosis. Learning, LLC of theNOT conditions FOR throughoutSALE OR this DISTRIBUTION book include a differen- ■ A definitiveNOT diagnosis FOR SALE should OR always DISTRIBUTION be obtained for tial diagnosis or listing of other conditions that may cause unknown oral or perioral abnormalities. similar lesions. Attention should be paid to these, and they should be incorporated into the student’s dental hygiene education. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION CHAPTER REVIEW

Case Study 1.1 approximately 5 mm in diameter, patient unaware, no symptoms, and no knowledge of trauma, etc., in Refer to Figure 1.52 for© Jonesthis case & study. Bartlett This Learning,panoramic LLC the area. © Jones & Bartlett Learning, LLC radiograph was taken NOTas part FORof an initial SALE examination OR DISTRIBUTION of a D. Patient has a lesion in NOTthe right FOR retromolar SALE area OR that DISTRIBUTION 25-year-old woman. she has no knowledge of. She reports no symptoms 1. Which of the following best describes this radio- of pain or other sensations and she says she doesn’t graphic finding? remember any trauma to the area. The lesion looks ©A. JonesRound radiopaque & Bartlett circle Learning, in the right mandible.LLC round© andJones has a &white Bartlett ring around Learning, it. It is about LLC the B. Thin radiopaque ring about 5 mm in diameter sur- size of a dime on the radiograph. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION rounding normal-appearing bone distal to #31. 2. Based on the radiograph alone, list some questions you C. Single round well-circumscribed area of normal- might want to ask this patient to determine a differen- appearing bone surrounded by a thin distinct tial diagnosis? radiopaque margin in the right retromolar area 3. How would you clinically evaluate the area? © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284209372_CH01_001_025.indd 22 26/03/20 5:09 PM CHAPTER 1 Introduction to General and Oral Pathology 23

© Jones & BartlettFIGURE Learning, 1.52. LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOTquadrant. FOR SALE High-volume OR DISTRIBUTION evacuation and a saliva ejec- For answers and additional review activities, please tor were used to help maintain a clear field of operation. visit the Navigate 2 Preferred Access site. Tracie is returning for her second periodontal debridement today. Before beginning treatment, you review the medical and the dental history, obtain vital signs, and © Jones & Bartlett Learning, LLCupdate her extra and intraoral© examinations. Jones & Bartlett You discover Learning, LLC Case Study 1.2 NOT FOR SALE OR DISTRIBUTIONthe lesion seen in Figure 1.53.NOT You are FOR quite SALE startled OR at the DISTRIBUTION Your patient, Tracie, is a 34-year-old woman. Two days bright red color and the fact the lesion was not there 2 ago, you performed periodontal debridement with ultra- days ago. sonic and hand instruments in the mandibular right 1. Write a complete clinical description of the lesion (size © Jones & Bartlett Learning, LLC approximately© Jones 1 cm & in Bartlett diameter, consistencyLearning, soft). LLC 2. Write out some questions you could ask her to help NOT FOR SALE OR DISTRIBUTION you determineNOT FOR a differential SALE diagnosis.OR DISTRIBUTION (Look at the following conditions in Chapter 12 for help in developing your questions—petechiae, ecchymoses, and purpu- ra; erosive lichen planus; erythematous candidiasis; © Jones & Bartlett Learning, LLC © Joneserythroplakia; & Bartlett congenital Learning, hemangioma.) LLC 3. Look at the conditions listed above and see if any can NOT FOR SALE OR DISTRIBUTION NOT FORbe eliminatedSALE OR based DISTRIBUTION only on the information given in this case study so far. 4. In your opinion, what is the definitive diagnosis? Support your opinion with information from the case. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION For answers and additionalNOT review FOR activities, SALE please OR DISTRIBUTION visit the Navigate 2 Preferred Access site.

© Jones & Bartlett Learning, LLC Chapter 1© Review Jones Questions & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 1. Which one of the following is a descriptive term for “consistency”? A. Rough B. Fissured C. Fluctuant © Jones & Bartlett Learning, LLC © JonesD. &Endogenous Bartlett Learning, LLC NOT FOR SALEFIGURE OR 1.53. DISTRIBUTION NOT FORE. Pedunculated SALE OR DISTRIBUTION

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2. The term “oral medicine” refers to which one of the 11. Radiographic evidence indicating a more aggres- © Jones & Bartlettfollowing? Learning, LLC © Jonessive & lesionBartlett includes Learning, all of the LLCfollowing EXCEPT one. NOT FOR SALEA. Maintaining OR DISTRIBUTION total health NOT FORWhich SALE one isOR the DISTRIBUTIONEXCEPTION? B. Medication taken by mouth A. Root resorption C. Nonsurgical management of oral diseases B. Bone expansion D. Dental speciality concerned with treating the “total patient” C. Distinct margins E. Medical speciality concerned with treating oropharyngeal D. Root displacement cancers © Jones & Bartlett Learning, LLC12. Which of the following is© a betterJones example & Bartlett of a clinical Learning, LLC 3. Which one of theNOT following FOR structures SALE OR is examined DISTRIBUTION description than the others?NOT FOR SALE OR DISTRIBUTION using bilateral palpation? A. Papule, 1 mm, red, left lateral tongue near #18 A. Tongue B. 1-mm red papule on the lateral border of the tongue B. Hard palate C. 1-mm red papule left lateral tongue near #18, unaware C. Temporomandibular joint D. Small red spot on the side of the tongue near the middle D. Submandibular lymph nodes © Jones & Bartlett Learning, LLC 13. Which ©one Jones of the following & Bartlett terms Learning,is defined as LLCa listing 4. WhichNOT FORone of SALEthe following OR DISTRIBUTIONobservations is consistent of the probableNOT FOR causes SALE of a group OR of DISTRIBUTION disease manifesta- with an aggressive condition? tions seen in a patient? A. Moveable A. Clinical diagnosis B. Nonulcerated B. Definitive diagnosis C. Irregular margins C. Differential diagnosis © Jones & BartlettD. Bilateral Learning, involvement LLC © JonesD. &Therapeutic Bartlett diagnosis Learning, LLC 5. NOT FOR SALEWhich OR one DISTRIBUTION of the following terms denotes the smallestNOT 14. FOR Which SALE of the OR following DISTRIBUTION procedures can provide a of the fluid-filled elevated lesions? definitive diagnosis of a suspicious lesion? A. Bulla A. Biopsy B. Vesicle B. Clinical observation C. Pustule C. Radiographic evaluation D. Therapeutic intervention 6. A/n © Jones lesion is &attached Bartlett to the Learning, underly- LLC © Jones & Bartlett Learning, LLC ing tissues by a thinNOT stalk. FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION A. Fixed Critical Thinking Activities B. Sessile 1. C. Fluctuant You have taken a position as a dental hygienist in an estab- D. Endophytic lished practice. You are told what you are expected to ©E. PedunculatedJones & Bartlett Learning, LLC accomplish© Jones during an& initialBartlett appointment, Learning, maintenance LLC appointments, and special appointments for sealants and 7. NOTWhich FORone of SALE the following OR DISTRIBUTION depressed lesions does periodontalNOT debridement. FOR SALE You ORnotice DISTRIBUTION nothing has been NOT extend through the epithelium? said about a cancer screening examination. You ask if A. Ulcer B. Erosion this is an oversight and are told that only the dentist per- C. Abrasion forms the cancer screening examination. What are your D. Laceration initial thoughts about this? Do you think this is a good © Jones & Bartlett Learning, LLC © Jonesprotocol & Bartlett for a dental Learning, practice? IfLLC yes, justify your answer. 8. NOT FOR SALEWhich OR one DISTRIBUTION of the following terms denotes the smallestNOT FORIf no, SALE what wouldOR DISTRIBUTION you do to try to change it? Research of the solid elevated lesions? your state’s dental practice act and report on what the A. Tumor B. Papule responsibility of the hygienist is in regard to this situation. C. Nodule 2. Refer to Figure 1.34 and the information in Application D. Plaque to Practice 1.2 for this activity. The patient has given you © Jones & Bartlett Learning, LLCthe following additional information:© Jones She& Bartlettstates that sheLearning, LLC 9. All of the followingNOT terms FOR describe SALE surface OR DISTRIBUTION texture has experienced frequentNOT dull aching FOR sensationsSALE OR from DISTRIBUTION EXCEPT one. Which one is the EXCEPTION? the area that get sharper just before, during, and for a A. Smooth B. Fissured short time after she eats. Does the additional informa- C. Papillary tion bring you any closer to a definitive diagnosis of the D. Indurated lesion? If so, in what direction is it leading you? ©E. CorrugatedJones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 10. A radiopaque area is darker or blacker than the sur- Media Menu rounding bone 2. A radiolucent area is whiter than the Web Sites surrounding bone. A. Both statements are true. Healthy People 2020 http://healthypeople.gov/2020/ © Jones & BartlettB. Both statements Learning, are false.LLC © Jonesdefault.aspx & Bartlett Learning, LLC C. Statement 1 is true, and statement 2 is false. https://www.healthypeople.gov/2020/ NOT FOR SALED. Statement OR DISTRIBUTION 1 is false, and statement 2 is true. NOT FORtopics-objectives/topic/oral-health SALE OR DISTRIBUTION

9781284209372_CH01_001_025.indd 24 26/03/20 5:09 PM CHAPTER 1 Introduction to General and Oral Pathology 25

Prevent Abuse and Neglect through Dental Study Tools © Jones & BartlettAwareness Learning, (P.A.N.D.A.) LLC © Jones & Bartlett Learning, LLC NOTTake FOR advantage SALE ofOR additional DISTRIBUTION online resources to help you NOT FOR SALEhttp://www.healthy.arkansas.gov/programsServices/ OR DISTRIBUTION study and ace your exams! oralhealth/Pages/PANDA.aspx ■ Answers to case studies in the book Oral Health in America: A Report of the Surgeon ■ Additional interactive case studies General ■ Interactive quiz bank with answer feedback http://www.nidcr.nih.gov/DataStatistics/© Jones & Bartlett Learning, LLC ■ Clinical protocol e-book © Jones & Bartlett Learning, LLC SurgeonGeneral/sgr/welcome.htmNOT FOR SALE OR DISTRIBUTION ■ Condition summary tablesNOT FOR SALE OR DISTRIBUTION ■ Expanded Media Menu with direct links to related dentalcare.com: Crest® Oral-B® online continuing Web sites and multimedia resources education program The Intraoral and Extraoral Exam ■ Supplemental references http://www.dentalcare.com/en-US/dental-education/ continuing-education/ce337/ce337.aspx?Module Name= © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC introduction&PartID=−1&SectionID=−1 Online resources and links are available at through NOT FOR SALE OR DISTRIBUTION theNOT Navigate FOR 2 Preferred SALE Access OR SiteDISTRIBUTION SEER Cancer Statistics Factsheets: Oral Cavity and Pharynx Cancer. National Cancer Institute. Bethesda, MD http://seer.cancer.gov/statfacts/html/oralcav.html

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION References Howlader N, Noone AM, Krapcho M, et al. (eds.). SEER Cancer Statistics Review, 1975–2013, Bethesda: National Cancer American Cancer Society. Cancer Facts & Figures 2016. Atlanta: Institute, Available at: http://seer.cancer.gov/csr/1975_2013/, American Cancer Society, 2016. Available at: http://www.cancer. based on November 2015 SEER data submission, posted to the org/acs/groups/content/@research/documents/document/© Jones & Bartlett Learning, LLCSEER web site, April 2016. Available© Jones at: http://seer.cancer.gov/ & Bartlett Learning, LLC acspc-047079.pdf, accessedNOT June FOR 2016. SALE OR DISTRIBUTIONcsr/1975_2013/, accessed June 2016.NOT FOR SALE OR DISTRIBUTION Awojobi O, Scott SE, Newton T. Patient’s perceptions of oral cancer Luryi AL, Day T, Nathan CO, et al. Public awareness of head and neck screening in dental practice: a cross sectional study. BMC Oral cancers: a cross-sectional survey. JAMA Otolaryngol Head Neck Health 2012;12(55):55. Surg 2014;140(7):639–646. Forrest JL, Horowitz AM, Shmuely Y. Dental hygienists’ knowledge, Riley JL, Pomery EA, Dodd VJ, et al. Disparities in knowledge of opinions, and practices related to oral and pharyngeal cancer risk mouth or throat cancer among rural Floridians. J Rural Health assessment.© Jones J Dent & HygBartlett Fall 2001;75(IV):271–281. Learning, LLC 2013;29(3):294–303.© Jones & Bartlett Learning, LLC HealthyNOT People FOR 2020 SALE[Internet]. OR Washington, DISTRIBUTION DC: U.S. Department U.S. DepartmentNOT of Health FOR and HumanSALE Services. OR DISTRIBUTIONOral health in America: of Health and Human Services, Office of Disease Prevention a report of the Surgeon General. Rockville: U.S. Department of and Health Promotion Available at https://www.healthypeople. Health and Human Services, National Institute of Dental and gov/2020/topics-objectives/topic/oral-health Accessed June 2016. Craniofacial Research, National Institutes of Health, 2000. Horowitz AM, Siriphant P, Canto MT, Child WL. Maryland dental Walsh MM, Rankin KV, Silverman S Jr. Influence of continuing educa- hygienists’ views of oral cancer prevention and early detection. tion on dental hygienists’ knowledge and behavior related to oral can- © Jones & BartlettJ Dental Hyg Learning, Summer 2002;76(III):186–191. LLC © Jonescer screening& Bartlett and tobacco Learning, cessation. J DentLLC Hyg 2013;87(2):95–105. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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