Clinical Evaluation of Oral Diseases

Chizobam N. Idahosa and A. Ross Kerr

Abstract a comprehensive clinical examination, Oral medicine is concerned with the diagnosis performing vital signs, and ordering appropri- and non-surgical management of medically ate investigations that provide the clinician related disorders of the oral and maxillofacial with key information vital to establishing a region as well as the oral health management of final diagnosis. The categories and classifica- medically compromised patients. Oral diseases tion systems of oral diseases as well as the have a wide range of clinical presentations and indications for referrals and consultations can manifest either as a local oral disease or as with other health-care providers and guidelines a sign of an underlying systemic condition. for documentation are reviewed. Therefore, oral health is a vital component of overall systemic health and an oral lesion may Keywords in certain situations be the initial presentation Medical history • Physical examination • of a systemic disorder. Consequently, it is Extraoral examination • Intraoral examination • imperative that oral health-care providers and Differential diagnosis • Definitive diagnosis • physicians are adequately trained to accurately Documentation diagnose and manage diseases affecting the oral and maxillofacial region. This chapter Contents addresses the systematic approach required Introduction ...... 2 for the evaluation of patients who present with oral diseases. This includes the process The Medical Record ...... 2 of obtaining a thorough history, performing The Patient History ...... 2 The Patient Examination ...... 11 Imaging ...... 24 Diagnosis ...... 25 C.N. Idahosa Department of Oral and Maxillofacial Pathology, Medicine Referral/Consultation ...... 32 and Surgery, Temple University Kornberg School of Documentation ...... 34 Dentistry, Philadelphia, PA, USA e-mail: [email protected] Conclusion and Future Directions ...... 34 A.R. Kerr (*) Cross-References ...... 34 Department of Oral and Maxillofacial Pathology, References ...... 34 Radiology & Medicine, New York University College of Dentistry, NY, New York, USA e-mail: [email protected]

# Springer International Publishing AG 2017 1 C.S. Farah et al. (eds.), Contemporary Oral Medicine, DOI 10.1007/978-3-319-28100-1_3-1 2 C.N. Idahosa and A.R. Kerr

Introduction The Medical Record

Oral medicine is a specialty at the interface of The patient’s medical information obtained from a medicine and dentistry focused on the diagnosis clinical evaluation is considered confidential and and nonsurgical management of medically related must be carefully documented and stored for disorders of the oral and maxillofacial region future reference in a safe and protected manner. (Scully et al. 2016; Stoopler et al. 2011). The The medical record is collected either as a paper- scope of practice of an oral medicine specialist based health record or as an electronic health involves the evaluation of patients with a wide record (EHR). Transmission of information range of maxillofacial conditions including “oral between multiple providers caring for the same mucosal disorders, orofacial pain, temporoman- patient is often inefficient, prone to errors, and dibular disorders, salivary gland disorders, slow with the use of paper-based health records. chemosensory disorders, sleep disorders, oral As clinical management of patients often requires manifestations of systemic disorders, as well as input from multiple health-care providers, there the dental treatment of medically compromised has been a move by many countries to implement patients” (Sollecito et al. 2013). The oral cavity the use of EHR as a means of improving safety, is the gateway to the body; therefore, oral health is efficiency, and accessibility of records across an essential component of overall systemic health. multiple sites (Ludwick and Doucette 2009). Many systemic disorders have oral manifesta- Irrespective of the type of record used, it is the tions; conversely, the oral management of patients responsibility of the oral health-care provider to may be impacted by the presence of systemic obtain and record all information relevant to the disorders (Stoopler and Sollecito 2016). There- patient’s treatment including all aspects of the fore, it is important that oral health-care providers history, examination findings, vital signs, and are trained, not only to diagnose and manage investigational reports such as clinical photo- patients with odontogenic diseases (i.e., dental graphs, radiographs/medical imaging studies, lab- caries/odontogenic infections, periodontal dis- oratory tests, and histopathological findings. eases, and malpositioned teeth/jaws) but also to effectively diagnose other oral diseases within the scope of oral medicine and provide safe dental The Patient History treatment to those patients with underlying sys- temic disorders (Miller et al. 2001). This chapter The history is the information relevant to the addresses the necessary steps involved in the eval- patient’s health obtained by careful interview of uation of patients who present with such diseases, the patient or a reliable source. For new patients, both soft and hard tissue diseases. This includes the initial goal of the history is to help reach a final the process of obtaining a thorough history, diagnosis and formulate a treatment plan. For an performing a comprehensive clinical examina- established patient, the goal is to elicit new infor- tion, performing vital signs, and ordering appro- mation to facilitate ongoing care. The patient’s priate investigations such as laboratory tests and history alone often reveals key elements of the imaging, that provide the clinician with key infor- information needed to reach a definitive diagno- mation vital to establishing a final diagnosis. The sis, and the importance of a thorough and system- categories and classification systems of oral dis- atic approach to collect this information cannot be eases as well as a general overview of the diag- underestimated. The history also aids in the risk nostic process, the indications for referrals and assessment of patients prior to the provision of consultations with other health-care providers, oral care as medical conditions that may increase and guidelines for documentation are reviewed. the risk of adverse events and complications in the dental setting are identified. Likewise, through the history, symptoms that may indicate the presence of undiagnosed health conditions may be Clinical Evaluation of Oral Diseases 3 recognized. The process of history-taking pro- Table 1 Elements of the new patient encounter vides an opportunity for the clinician to develop Chief concern a rapport with the patient, which is necessary for History of presenting concern effective communication during the interview and Onset of symptoms subsequent encounters. It is important for the cli- Anatomic site(s) Description of symptom(s) nician to make the patient comfortable bearing in Precipitating factors mind that patients come from diverse social and Aggravating/relieving factors cultural backgrounds with differing attitudes and Secondary signs or symptoms beliefs to health care. The clinician should there- History of past investigations and treatments fore encourage the participation of the patient in Medical history Current medical diagnoses decision-making and should listen to the patient’s Past medical history perceptions and concerns regarding their clinical Current medications problems respectfully and without bias. It is also Allergies important that the clinician greets the patient in a Review of systems Family medical history culturally appropriate manner, ensures that the Sexual history interview location is private, and pays attention Social history to the patient during the interview. The use of Relationship status open-ended questions is preferred to direct Children questioning and clarification of the patient’s Occupation Cultural and religious beliefs understanding should be sought when appropri- Tobacco use ate. Language barriers can be a major issue, and Alcohol use interpreters should be on hand to facilitate com- Illicit drug use munication. In addition, parents or legal guardians Recent travel history Dental history must accompany minors and those with disabil- Current dental symptoms ities that limit communication. An exhaustive Last dental visit and reason for seeking dental care systematic approach should be followed for Frequency of dental visits every patient, whether new or established. This Previous dental treatments History of maxillofacial trauma will maximize the opportunity to capture all rele- Home care vant information and minimize the risk of missing Oral habits something. The master clinician with years of TMJ history experience can often quickly and efficiently nav- Exposure to fluoride and type of fluoride Presence of dental phobia igate the history, whereas the novice may be less Nutritional history efficient and take longer. The road to mastery is Extraoral examination built on a disciplined systematic approach where General inspection there is no room for shortcuts. Table 1 provides Skin/hair the elements for taking both a new and established Eyes patient history. TMJs Muscles of mastication Biographical data: The biographical data are Salivary glands important for identification and administrative Midline neck structures purposes as well as to ensure that the patient’s Lymph nodes contact information is accurate and available for Intraoral examination use when needed. This includes the patient’s Lips Labial mucosae name, contact information, date of birth, gender, Buccal mucosae race/ethnicity, primary language, occupation, and Gingivae primary care physician’s name and contact infor- Tongue mation (and other pertinent specialists). Hard palate Oropharynx Chief concern: The chief concern states why Floor of mouth the patient is in your office. It is a brief description (continued) 4 C.N. Idahosa and A.R. Kerr

Table 1 (continued) Table 2 History of present illness Dentition Questions for patients with ulcerative lesions Saliva When did it start? Cranial nerves (I–XII) How did it start? Vital signs Any history of trauma? Blood pressure Is this the first episode or is it recurrent? Heart rate and rhythm How many? Single or multiple? Respiration Temperature Do the old ones heal before new ones come up? Imaging Any pain, sensitivity to spicy foods, difficulty eating or Photography/videography swallowing? Plain films Any extraoral sites involved? Skin, genital, scalp, Computed tomography (CT) ocular. Magnetic resonance imaging (MRI) Did you start a new medication or oral hygiene Sialography product? Diagnosis Any associated systemic symptoms such as fever and Differential diagnosis/working diagnosis malaise? Definitive diagnosis Does anyone in your family have similar problems? Treatment Do you have any gastrointestinal symptoms such as diarrhea and bleeding? of the primary reason for the patient’s consultation Any joint pain? Questions for patients with salivary gland disorders: and evaluation recorded in the patient’s own When did the problem start? words. Examples of chief concerns include oral Any swelling? Where is the swelling? Is it associated lesions, pain, altered sensations (e.g., numbness, with meals? taste alterations), dry mouth or too much saliva, Any pain? Where is the pain? Is it associated with halitosis, slow healing of a surgical wound, facial meals? or oral/neck swelling, abnormal bleeding, an alter- Is your mouth dry? ation in oral function (e.g., chewing, swallowing Has the texture of your saliva changed? etc.), or tooth abnormalities. Any pus draining? History of presenting concern: The history of Are your eyes dry? presenting concern is an exhaustive chronological Any joint pain? account of all aspects of the chief concern Any associated systemic symptoms such as fever and malaise? obtained by carefully interviewing the patient. Does anyone in your family have similar problems? The following information should be documented Questions for patients with temporomandibular joint as part of the history of presenting concern, and disorders: the reader is alerted to Table 2 where examples of When did the symptoms start? specific questions for selected categories of chief Any precipitating factors such as trauma or prolonged complaints are provided. mouth opening? Any joint sounds in the past or currently? (i) Onset of symptoms: Determine when the Is your mouth opening restricted? symptoms started and if the onset was sud- Has your jaw ever locked in the past? den or gradual. Do you clench or grind your teeth? (ii) Anatomic site(s): Determine the anatomic Has your occlusion changed? Do you have joint/muscle pain affecting other parts of site affected and ascertain whether the your body? symptoms involve a single anatomic loca- Any altered sensation? tion or multiple sites. (iii) Description of symptoms: This includes a description of the course of symptoms and if the symptoms are occurring for the first their characteristics considering both quali- time or recurring. Determine if the symp- tative and quantitative descriptors. Establish toms are constant or episodic. Also, find out Clinical Evaluation of Oral Diseases 5

if symptoms are stable, worsening, or modalities. The oral health-care provider improving. Ask the patient to describe the should determine if the patient has been characteristics of the symptoms, in their diagnosed with any of the medical condi- own words, using qualitative descriptors tions listed in Table 3. Information relevant such as dull, sharp, throbbing, aching, stab- to the onset of diagnosis, course of disease, bing, electric shock-like, burning, dry, itchy, associated complications, and level of con- thick, rough, bumpy, swollen. Pain or dis- trol should be documented. This will facil- comfort should be rated quantitatively using itate risk assessment and the identification a scale such as visual analog/numerical rat- of conditions that may necessitate modifi- ing scale from 1 (minimal) to 10 (unbear- cations to treatment. In addition, it is impor- able) or a Wong-Baker Faces scale (Fig. 1) tant to include information on routine (Wong-Baker FACES Foundation 2016). health maintenance, the type of medical Enquire about the impact of the symptoms specialist managing the patient, as well as on the patient’s quality of life. the frequency of office visits. For example, (iv) Precipitating factors: Enquire about any fac- the medical history on a 57-year-old dia- tors that triggered the onset or that exacer- betic female patient would include informa- bated the symptoms. tion on date of diagnosis, frequency of (v) Aggravating/relieving factors: Determine office visits to her endocrinologist and/or what makes the symptoms better or worse. primary care physician, home blood glu- (vi) Secondary signs or symptoms: These are cose test results, HbA1c, and target organ separate from the primary symptom(s) and damage. The medical history should also often the patient may be unaware they may include all relevant details of treatment be correlated with the underlying problem modalities, which can potentially alter the (e.g., primary herpetic gingivostomatitis can delivery of care, such as implanted defibril- be associated with fever and malaise, or lators in patients with cardiovascular disor- sleep issues may lead to an increase in ders, chemotherapy scheduling in oncology orofacial pain). patients, dialysis scheduling in patients (vii) History of past investigations and treat- with end-stage renal disease, and chronicle ments: Prior diagnoses, investigations, and of total joint replacements. treatment modalities for the chief concern (ii) Past medical history: Patients should be should be noted including pertinent negative asked if they have had any relevant medical results and failed treatments such as medi- problems in the past. The history should cation regimens. include previous major illnesses, consulta- tions and referrals to specialists and their Medical history: Although a self- outcomes, hospitalizations, surgeries, administered health history form is routinely uti- major trauma, and blood transfusions. lized for obtaining medical history information (iii) Current medications: Document all current from patients, it is not equivalent to an exhaustive medications and supplements taken by the history. It is imperative that the oral health-care patient. These include prescription medica- provider verbally reviews all entries on the health- tions, over-the-counter medications, vita- history form with all patients, and supplements the mins, herbal supplements, and traditional history with additional questions as deemed home remedies. The name, dosage, route, necessary. frequency, start date, and reason why the patient is taking each medication should be (i) Current medical diagnoses: A thorough noted. Online medication references have medical history should be elicited to evolved rapidly and are indispensable tools include details of the patient’s current med- that should be utilized for checking the ical diagnosis as well as treatment category, mechanism of action, dosing and 6 C.N. Idahosa and A.R. Kerr

Fig. 1 Wong-Baker FACES® Pain Rating Scale. After explaining to the patient that each face represents a person with no pain, some, or a lot of pain, the patient is asked to choose the face that best depicts the pain they are experiencing

Table 3 Pertinent medical history. Cardiovascular Hypertension, congestive heart failure, angina, myocardial infarction, arrhythmia, infective endocarditis, rheumatic heart disease Pulmonary Asthma, emphysema, tuberculosis, seasonal and environmental allergies Endocrine Diabetes, thyroid disease, Addison’s disease, Cushing syndrome Hematologic Sickle cell anemia, other forms of anemia, leukemia, lymphoma, multiple myeloma, other hematologic disorders Genitourinary Kidney disease Gastrointestinal Peptic ulcer, GERD, Crohn’s disease, ulcerative colitis, hepatitis, cirrhosis Neurologic Epilepsy/seizures, CVA, headaches, multiple sclerosis Psychiatric/ Anxiety, depression, eating disorders, drug abuse and dependence, bipolar, schizophrenia emotional Musculoskeletal Osteoarthritis, osteoporosis, rheumatoid arthritis Infectious HIV/AIDS diseases Skin Rashes, ulcers Malignancy GERD gastroesophageal reflux disease, CVA cerebrovascular accident, HIV human immunodeficiency virus, AIDS acquired immunodeficiency syndrome

administration details, adverse reactions, immunosuppressants (e.g., corticoste- and interactions. When possible, the roids), immunomodulators, and medica- generic medication name should be used tions for treating cancer (e.g., for the purposes of recording the medica- chemotherapy and immune therapies). tions in the patient’s record. When patients (iv) Allergies: History of drug, food, and envi- are unsure of the medications they are tak- ronmental allergies should be carefully ing, it is important to seek clarification from documented. The type of allergic reaction their physician or pharmacist. Clinicians experienced as well as the severity of the should be alerted to specific medications episode should be noted (e.g., contact der- that have increased potential for adverse matitis, anaphylactic reaction). It is impor- events and that can influence treatment tant to make a distinction between adverse decisions, such as antiresorptive agents reactions to medications and true allergy. (e.g., bisphosphonates), anticoagulants, For example, gastrointestinal side effects Clinical Evaluation of Oral Diseases 7

such as nausea, vomiting, and constipation examination findings should be may not be related to an allergic reaction. documented. This is particularly relevant (v) Review of systems: The review of systems to infectious diseases with the potential to is a careful and systematic review of rele- have oral manifestations including as vant signs and symptoms related to differ- human immunodeficiency virus (HIV) ent body systems that the patient may be infection, syphilis, gonorrhea, human pap- experiencing or has experienced in the illoma virus (HPV) infections, herpes sim- recent past (see Table 4). As an integral plex virus (HSV) infection, infectious part of the medical history, the review of mononucleosis, and hepatitis B or C. systems is helpful in identifying other med- (viii) Psychological history: The psychological ical problems that have not yet been diag- history is an important element of the med- nosed (e.g., polydipsia, polyphagia, ical history that may be overlooked. polyuria in a patient who has not been diag- Patients suffering from depression, anxiety, nosed with diabetes mellitus). Review of or other mental illnesses require careful systems is also helpful in assessing the evaluation, and a comprehensive history severity of diagnosed medical problems. of their clinical course and treatments, An example would be dyspnea with mild including medications, must be elicited. activity versus strenuous exercise in a Patients who appear to have undiagnosed patient diagnosed with congestive heart mental illness should be referred to a pri- failure. Finally, the review of systems can mary care provider. uncover pertinent details relevant to the chief concern/history of presenting con- Social history: The patient’s social history will cern, which will aid in reaching a diagnosis reveal information about the following domains: (e.g., skin and genital lesions in a patient with oral ulcers secondary to Behcet’s dis- (i) Relationship status: This will provide ease). Both positive and negative responses insight on the level of support available to should be documented. All positive the patient. Find out whether the patient is responses should be followed up with single, married, divorced, in a domestic more in-depth and focused questions and partnership, or in a long-term relationship. these patients should be referred to their (ii) Children: Find out if the patient has chil- physicians for further evaluation and man- dren and their level of dependency. Alter- agement as indicated. natively, if they are older, can they provide (vi) Family medical history: This should additional support as needed by the patient? include information on hereditary diseases (iii) Occupation: It is helpful to know the type (e.g., hemophilia), familial illnesses (e.g., of work the patient does (e.g., outdoors recurrent aphthous stomatitis, hyperten- vs. indoors). sion, diabetes mellitus, cancers, psychiatric (iv) Cultural and religious beliefs: With the disorders, alcohol, and drug addiction), growing trend in immigration and popula- contagious infections (e.g., tuberculosis), tion migration, oral health-care providers and illnesses arising from environmental should be cognizant of the fact that patients exposure to toxins. The relationship of the come from different backgrounds with var- patient to the affected relative, current sta- ious cultural and religious beliefs, which tus of the relative (alive or deceased) and can impact provision of care. Patients cause of death if deceased should be noted. from certain ethnicities may decline oral (vii) Sexual history: Information related to the medications and opt for herbal and tradi- patient’s sexual history (sexual relation- tional remedies while others may be unable ships, practices, and number of partners) to comply with instructions during periods relevant to their chief concern or of fasting. Also, based on their religious 8 C.N. Idahosa and A.R. Kerr

Table 4 Review of systems General Recent weight change, fatigue, malaise, fever, chills, night sweats Dermatologic Rashes, lumps, ulcers, dryness, pruritus, finger clubbing, nail changes Head Headaches, dizziness, head trauma Eyes Changes in vision and visual fields, spots, floaters, diplopia, blurriness, dryness, tearing, itching, Ears Hearing loss, pain, discharge, tinnitus, vertigo Nose, sinuses Stuffiness, sneezing, rhinorrhea, itching, epistaxis, changes in sense of smell Mouth, throat, Bleeding or painful gums, lesions, dental pain, halitosis, altered taste, hoarseness, sore throat, neck dysphagia, neck swelling Respiratory Dyspnea, chest pain, wheezing, cough, sputum, hemoptysis Cardiovascular Chest pain, palpitations, orthopnea, dyspnea on exertion, paroxysmal nocturnal dyspnea, peripheral edema Gastrointestinal Appetite changes, abdominal pain, nausea, vomiting, diarrhea, constipation, heart burn, belching, bloating, flatulence, dysphagia, bleeding (hematemesis, hemorrhoids, melena, hematochezia), jaundice, ascites Genitourinary Frequency, hesitancy, urgency, incontinence, nocturia, dysuria, hematuria, abnormal genital discharge, genital lesions, changes in libido Endocrine Polydipsia, polyuria, polyphagia, heat and cold intolerance, weight gain or loss, excessive sweating, thyroid enlargement or pain Hematologic Anemia, easy bruising or bleeding, lymphadenopathy Musculoskeletal Arthritis, arthralgia, pain, swelling, redness, limitations in range of motion, muscle weakness, trauma Neurologic Seizures, memory loss, loss of consciousness, paresthesia, anesthesia, muscle weakness, paralysis, Gynecologic Menopause, menstrual changes, dysmenorrhea Psychiatric/ Mood, anxiety, depression, changes in sleep pattern, decreased ability to concentrate emotional

doctrine that blood is sacred, Jehovah’s providers can make a significant impact Witnesses do not accept transfusion of by asking every patient about tobacco use whole blood and its four major derivatives and providing applicable tobacco cessation (red cells, white cells, plasma, and platelets) educational resources. They should be but may accept transfusion of blood prod- aware of the different types of tobacco ucts such as clotting factors, erythropoietin, products available, such as smoked tobacco and immunoglobulins (Sarteschi 2004). products (cigarettes, cigars, and pipe), (v) Tobacco use: Tobacco use is a leading clove cigarettes known as kreteks, bidis cause of preventable death. According to (coarse tobacco rolled in a tree leaf from the World Health Organization (WHO), South Asia), hookah (the smoking of fla- there are 1 billion smokers worldwide and vored tobacco with a form of water-pipe tobacco use is a public health threat leading (Waziry et al. 2016)), and smokeless to the death of approximately 6 million peo- tobacco formulations including snuff, snus ple a year (WHO 2016). Tobacco products (Swedish-style tobacco), and paan/betel adversely affect nearly every human organ quid (areca nut and tobacco wrapped in a system. Exposure leads to the development betel leaf and chewed), gutkha (an areca nut of a wide range of disorders including sys- tobacco mixture sold in single use sachets temic diseases (e.g., cardiovascular dis- and chewed) (Couch et al. 2016). E-ciga- eases, respiratory diseases, and cancers) rettes are relatively new handheld nicotine and oral diseases (e.g., periodontal disease, delivery systems that produce a vaporized oral potentially malignant disorders, and flavored liquid by pressing a button. The oral cancer) resulting in reduced quality of long-term oral and systemic health risks of life and life expectancy. Oral health-care e-cigarettes are currently unknown (Couch Clinical Evaluation of Oral Diseases 9

et al. 2016). The risk of oral and pharyngeal Institute on Alchohol Abuse and Alcohol- cancers increases the longer a person ism 2005). It is also important to assess the smokes. The use of paan, betel quid and impact of alcohol, if any, on the patient’s related products, which are usually placed quality of life by finding out if alcohol has in the oral vestibules, increases the risk of adversely affected their mood, behavior, submucous fibrosis, a precancerous condi- diet, occupation, and relationships tion characterized by oral burning and lim- (Table 5), in which case referral to a medi- ited mouth opening (Tilakaratne et al. cal professional may be indicated. 2016). The tobacco history, therefore, (vii) Illicit drug use: This encompasses the non- should include information on current and medical use of prescription drugs (e.g., opi- past use, the type of tobacco products, dura- oids, barbiturates, and amphetamines) and tion and frequency of use, and details about illicit drugs (such as cocaine and heroin) cessation attempts, if any. A cumulative (Degenhardt and Hall 2012). Marijuana is cigarette smoking history should be considered an illicit drug in most countries. documented in pack-years (number of Enquire about current and past history of 20 cigarette-packs per day multiplied by drug use, the type(s) used, the route of the number of years smoked). administration (i.e., intravenous, inhaled, (vi) Alcohol use: Alcohol use disorder is com- smoked, or consumed by mouth), and any mon in society and alcohol use can lead to treatment for addiction. It is important to multiorgan consequences, some of which consider prescribing medications without carry significant morbidity and mortality increased potential for addiction to patients (e.g., liver cirrhosis). Studies have shown with a history of drug abuse and depen- an association between the consumption of dence. Also, current use of some illicit alcohol and the risk of oral cancer (Ogden drugs may potentially interact with local 2005). Alcohol potentiates the carcinogenic anesthesia or medications prescribed by effect of tobacco in a synergistic manner, oral physicians (e.g., cocaine). thereby multiplying the risk of oral cancer (viii) Recent travel history: This has become (Petersen 2009; Reidy et al. 2011). Oral more important with respect to recent travel health-care providers can and should elicit to geographic regions with endemic dis- a history of alcohol use, and collect infor- eases such as tuberculosis, Ebola, leish- mation about current or past use, types of maniasis, or Zika virus. alcoholic beverages consumed, current drinking patterns (i.e., how many days a Dental history: The dental history can provide month or week, the time of day when the additional information related to the chief concern patient consumes alcohol), and quantity that is valuable in reaching a diagnosis. It is also (number of units of alcohol/week). It is important for evaluating the patient’s level of den- important to appreciate the dose equiva- tal awareness, motivation, utilization of dental lents for alcoholic beverages [i.e., a 12 oz. services, and risk/susceptibility for dental disease. beer (5% alcohol) is equivalent to a 5 oz. The following should be documented as part of glass of table wine (12% alcohol) or a the dental history: 1.5 oz. distilled alcoholic drink (40% alco- hol)]. Low risk use is defined as either (i) Current dental symptoms: pain, swelling, fewer than 3 units of alcohol at a sitting or halitosis, bleeding, mobile, or fractured 7 or less units of alcohol/week for women, teeth and either fewer than 4 units at a sitting or (ii) Last dental visit and reason for seeking 14 or less units of alcohol/week for men. dental care: emergency or routine dental Higher rates carry significantly higher rates care for alcohol use disorder (NIAAA. National (iii) Frequency of dental visits 10 C.N. Idahosa and A.R. Kerr

Table 5 Assessment for alcohol use disorder In the past year have you? 1. Had times when you ended up drinking more, or longer than you intended? 2. More than once wanted to cut down or stop drinking, or tried to, but couldn’t? 3. Spent a lot of time drinking? Or being sick or getting over the aftereffects? 4. Experienced craving, a strong need, or urge, to drink? 5. Found that drinking, or being sick from drinking, often interfered with taking care of your home or family? Or caused job troubles? Or school problems? 6. Continued to drink even though it was causing trouble with your family or friends? 7. Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink? 8. More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)? 9. Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout? 10. Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before? 11. Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, irritability, anxiety, depression, restlessness, nausea, or sweating? Or sensed things that were not there?

(iv) Previous dental treatments: recall visits/ points may be considered when taking the nutri- dental prophylaxis, restorative dentistry, tional history: oral surgery, implants, orthodontics, peri- odontics, endodontics, and fixed and (i) Dental caries: There are multiple risk factors removable prosthodontics for dental caries, a number of which are (v) History of maxillofacial trauma modifiable, including diet. Therefore, the (vi) Home care: Brushing and flossing/inter- nutritional history should include informa- proximal habits (i.e., frequency, timing in tion on frequency of meals and snacks, and the context of meals, and technique). Oral a detailed history of the consumption of sug- hygiene products such as dentifrices, ared beverages (Marshall 2009) flosses, and mouthrinses should be (ii) Periodontal diseases: Severe vitamin C defi- recorded as they can sometimes cause ciency (i.e., scurvy) is associated with peri- mucosal reactions odontal disease. (vii) Oral habits: clenching, bruxism, cheek bit- (iii) Dental erosion: Repeated exposure to acidic ing, nail biting beverages (e.g., carbonated soda and sports (viii) History of temporomandibular joint (TMJ) drinks) can promote the initiation and pro- pain, clicking or locking, and the use of gression of dental erosion. Patients who suf- orthotic devices or night guards fer from eating disorders such as anorexia (ix) Exposure to fluoride and type of fluoride nervosa and bulimia may practice self- (x) Presence of dental phobia and anxiety induced vomiting leading to dental erosion on the lingual and palatal surfaces of teeth. Nutritional history: Nutritional factors are (iv) Oral cancer: a diet rich in fruits and vegeta- associated with the development and progression bles is protective against oral cancer. of various oral and systemic diseases. Therefore, it (v) Oral mucosal disorders and neuropathies: is necessary to evaluate the nutritional and dietary Vitamin B12 deficiency may occur in strict habits of patients in relation to their chief concern vegetarians and is associated with glossitis and presenting symptoms. Oral health-care pro- and stomatitis. Chronic undernutrition and viders may also play a role in the interception and other vitamin deficiencies (B2,B6, folic management of obesity and eating disorders (e.g., acid) may predispose patients to angular bulimia and anorexia nervosa). The following Clinical Evaluation of Oral Diseases 11

cheilitis, stomatitis, oral ulcerations, and minutes of the patient encounter. Height burning mouth symptoms. and weight may be combined to assess a (vi) Major salivary gland enlargement: May be patient’s body mass index (BMI), calcu- seen in patients with chronic malnutrition. lated as the weight in kilograms (kg) divided by the height in meters squared (m2). The Patient Examination (ii) Skin/hair: Clinicians should evaluate the head, face, and neck, or any other visible The history is followed by a comprehensive areas of skin (i.e., hands, arms, legs, or feet) visual/tactile head and neck examination. Medical noting the texture, turgor, color, and obvi- providers (i.e., primary care physicians) rarely ous asymmetry, growths, or lesions (e.g., perform a detailed intraoral examination, which pigmented or ulcerated skin lesions). Fin- underscores the important role of oral health-care gernails and hair distribution should also be providers in this regard. Yet, the patient examina- evaluated (e.g., hair loss or fingernail tion performed by oral health-care providers goes pathology such as onychomycosis). far beyond the evaluation of dental and periodon- (iii) Eyes: Observe general features such as eye tal structures. Clinicians should have detailed position, eyelids, lashes, and structures of knowledge of how to evaluate both oral and non- the eyeball (cornea, sclera, iris, pupils, tear oral structures of the head and neck, and perform a production, noting any asymmetry). cranial nerve examination. An understanding of Assessment of visual acuity and ocular normal anatomy and function facilitates the detec- function is covered in the cranial nerve tion of abnormalities during the examination. The assessment. interplay between the history and the examination (iv) Temporomandibular joints (TMJs): The deepens as the clinician explores new avenues of TMJs may be examined by placing the questioning based upon the detection of such index fingers anterior to the tragus of the abnormalities. This section emphasizes the impor- ears and asking the patient to open and tance of performing a consistent and comprehen- close their jaws (Fig. 2a). This will allow sive examination, a skill that is vastly undervalued the clinician to locate the lateral poles of the and yet, when performed correctly, can yield condyles, palpate any TMJ swelling or important clues to the diagnostic process. With pain, assess the rotation and translation of practice, this examination should not take longer the condyles, and detect joint sounds (i.e., than a few minutes on average. Table 1 summa- crepitus, clicks, or pops), or deviations/lim- rizes the steps. itations in the normal range of jaw move- Extraoral examination: This part of the ment. Subtle joint sounds may be examination has been broken into eight sections, appreciated more easily by using a stetho- and requires the patient to loosen/remove any scope. The range of motion is an easily clothing to allow visualization of the head and reproducible measure of jaw movement. neck structures: The normal range for maximum opening is variable (approximately 40–60 mm) and (i) General inspection: During the history tak- obtained by precisely measuring the ing an astute clinician has already begun the interincisal distance with a ruler (Fig. 2b) examination process by performing a visual or vernier calipers, or crudely by the num- inspection of the patient. Height and ber of fingers one is able to insert between weight; dress and personal hygiene; posture the teeth. Three fingers (measuring approx- and gait; dexterity and body movements; imately 47 mm) is a reliable surrogate for eye movements and facial expression; normal opening (Zawawi et al. 2003). speech, mood, and cognitive ability; and Observing excursive jaw movements (i.e., others may be gauged over the first few protrusion, or lateral excursions of 12 C.N. Idahosa and A.R. Kerr

Fig. 2 (a) Location of lateral pole of right TMJ. (b) Measurement of interincisal opening

approximately 7 mm) reveal limitations in of an algometer may assist in providing range, allow comparison between sides consistent pressure. The anterior (Fig. 3a) (i.e., asymmetry), and which movements, and more posteriorly the middle and poste- if any cause pain or other signs. rior aspects of the temporalis muscles may (v) Muscles of mastication and other head and be examined in turn, followed by the mas- neck musculature: There are four main seter muscles (Fig. 3b). The tendon of the pairs of masticatory muscles: masseters, temporalis at the coronoid process of the temporalis, medial pterygoids, and lateral mandible may be palpated intraorally. Ask pterygoids. All are innervated by the man- patients to provide a rating of any tender- dibular branch of the trigeminal nerve (V3), ness or pain (0 for no tenderness, 1 for and therefore V3 nerve function may be uncomfortable tenderness, 2 for definite assessed when examining these muscles. tenderness or pain, or 3 for significant The examination of the muscles of masti- pain that causes the patient to pull away to cation begins with a visual inspection for avoid further pain). The lateral and medial any asymmetry or gross enlargement of the pterygoids are difficult to reliably palpate masseters and temporalis muscles at rest. but may be assessed functionally. Pain Then the patient is asked to clench their elicited when protruding the jaw with resis- teeth in order to visualize and palpate mus- tance from the examiner may indicate the cle contraction and assess strength, symme- inferior lateral pterygoid muscles as a pos- try, and size of the muscles. At a minimum, sible source. The power stroke of biting digital palpation of the masseters and down on an object may result in pain from temporalis muscles should be performed the superior lateral pterygoid muscles. (the predictive value of palpating the pter- Neck muscles, such as the sternocleido- ygoids is low) and may reveal muscle ten- mastoids, posterior cervical muscles (i.e., derness or pain, or indicate sites of referred trapezius, longissimus (capitis and pain. It is important to assess each muscle cervicis), splenius (capitis and cervicis), in turn using consistent pressure (approxi- and levator scapulae), and strap muscles mately 1 kg), palpating at multiple points, of the neck may be similarly palpated and for approximately 2 s each, along the length also evaluated for range of motion by turn- of the muscles, comparing right to left. ing the head all the way to the left, then to Identified painful trigger points may be pal- the right, then lifting the chin up, and then pated for up to 5 s to appreciate referral tilting the head left and right. patterns (Schiffman et al. 2014). The use Clinical Evaluation of Oral Diseases 13

Fig. 3 (a) Palpation of right anterior temporalis muscle. (b) Palpation of right masseter muscle

(vi) Salivary glands: There are three paired which crosses in front of the trachea inferior major salivary glands (parotid, submandib- to the level of the cricoid cartilage. The ular, and sublingual glands) along with lobes extend laterally with the most lateral greater than 300 minor salivary glands dis- aspects of the gland found deep to the tributed throughout the mouth. Assessment sternocleidomastoid muscles (Fig. 4a). begins with a visual inspection of the The first step to examining the thyroid is parotid and submandibular glands for the inspection (both from in front and from swelling or asymmetry. There are a number the side of the patient) for any obvious of chronic disease processes (e.g., diabetes asymmetry or swelling (e.g., a goiter or or liver disease) that can manifest with thyroid neoplasm). Since the thyroid gland bilateral salivary gland enlargement. In moves with the trachea during swallowing, health, palpation of the salivary glands the patient can be asked to swallow a sip of will reveal a soft consistency without water, facilitating visualization as the thy- tenderness. roid tissue moves superiorly. This is (vii) Midline neck structures (trachea and thy- followed by palpation, performed either roid gland): Examination of the trachea is from behind (i.e., the posterior approach) warranted to rule-out displacement or or in front of the patient to detect any dis- change in axial mobility, possibly due to crete nodules within the gland or its associ- the encroachment of neck neoplasms. The ated lymph nodes. The prominence of the trachea extends inferiorly from the larynx, thyroid cartilage (Adam’s apple) is an easy and half of the trachea is within the neck. first landmark to detect manually. The next Tracheal displacement from its midline ring inferior is the cricoid cartilage, and just position may be verified by both inspection inferior to this is the location of the isthmus. and palpation of the trachea in relation to Pushing the sternocleidomastoid muscles the suprasternal notch. By gently grasping laterally and posteriorly, it is possible to the tracheal rings, the trachea can be moved palpate the lobes in turn by applying light laterally and a grating is appreciated pressure, comparing the right and left sides because of the movement of the cartilagi- for asymmetry (Fig. 4b). nous rings. Equal movement and grating is (viii) Lymph nodes: An understanding of the a normal finding. The thyroid is a bilobed lymphatic drainage of the head and neck is gland found in the midline of the lower a prerequisite for this step of the extraoral neck. The lobes are joined by an isthmus, examination. There is a collar of lymph 14 C.N. Idahosa and A.R. Kerr

Fig. 4 (a) Position of the thyroid gland and it’s isthmus i) in relation to thyroid cartilage (tc), cricoid cartilage (cc), and sternocleidomastoid muscle (scm). (b) Palpation of the thyroid gland

nodes of the head that drain into the deeper below the hyoid bone in the anterior central neck lymph nodes, which ultimately drain aspect of the neck. Following the examina- into the thorax (Fig. 5a, b). The head and tion of the thyroid gland, it makes sense to neck lymph node system is divided into begin the lymph node examination in the levels (I–VI) from superior to inferior. anterior triangle, then move into the poste- Superficially located lymph nodes are pal- rior triangle, and end with the submandib- pable in health, and they are soft, moveable, ular and submental triangles. The and nontender. Deeper nodes may become boundaries of the anterior triangle of the palpable when enlarged (lymphadenopa- neck are the midline of the neck anteriorly, thy). Most commonly, lymphadenopathy the sternocleidomastoid muscle posteriorly, is due to an inflammatory etiology (e.g., and the inferior border of the mandible an odontogenic infection) and involved superiorly (Fig. 6a). The level II, III, and lymph nodes become enlarged and tender, IV deep lateral cervical nodes follow the although they typically remain soft and path of the internal jugular vein deep to moveable. Lymphadenopathy can occur in the sternocleidomastoid muscle. Look for association with cancer metastasis (e.g., the outline of the sternocleidomastoid mus- squamous cell carcinoma) and are typically cles, and asking the patient to lift and turn enlarged, firm to palpation, nontender and, their head away from the side being exam- if there is extracapsular spread, they may ined is often helpful to identify this muscle. become nonmovable or fixed. Level I nodes With the neck relaxed, it is possible to pal- are detected in the submandibular and sub- pate anterior and deep to the muscle from mental triangles of the neck. Level II, III, superior to inferior, and compare findings and IV lymph nodes may be detected from both sides (Fig. 6b). The boundaries within the anterior triangle of the neck, of the posterior triangle are the sternoclei- and level V nodes in the posterior triangle domastoid muscle anteriorly, the trapezius of the neck. Level VI nodes are found muscle posteriorly, and the clavicle Clinical Evaluation of Oral Diseases 15

Fig. 5 (a) Collar of lymph nodes draining head and face. (b) Descending system of lymph nodes

inferiorly (Fig. 7a). Palpate along the pos- the soft tissues laterally across the inferior terior border of the sternocleidomastoid border of the mandible (Fig. 8b). In this muscle from the supraclavicular nodes infe- way, it is possible to “capture” the node riorly to the postauricular and occipital between the examiner’s finger and the infe- nodes superiorly (Fig. 7b). The submandib- rior border, and then feel the node “pop” ular and submental triangles comprise the back into place. Similarly, submental nodes most superior aspect of the anterior triangle may be palpated by moving the submental of the neck and contain level I nodes which soft tissues anteriorly (Fig. 8c). Lymph receive drainage from most oral structures nodes draining facial structures, such as (Fig. 8a). Submandibular nodes are gener- the preauricular and buccal nodes may ally superficial and therefore palpable in also be palpated. health, allowing the examiner to feel the characteristics of healthy nodes. Have the Intraoral examination: This part of the exam- patient lower their chin and then gently pull ination is rarely performed in a comprehensive 16 C.N. Idahosa and A.R. Kerr

Fig. 6 (a) Boundaries of the anterior triangle of the neck. (b) Palpation of the deep cervical nodes

manner by health-care providers outside of den- portable light-emitting diode (LED) white head- tistry, and as such, it is critical to perform it when light affixed to loupes in order to keep both hands the opportunity arises, certainly for all new free. Other adjuncts include an air syringe, mouth patients, for all recall visits, and during emer- mirrors, and gauze. gency/urgent care visits regardless of the type of emergency/urgency. Patients should be informed (i) Lips: The lips’ vermillion border with the that they are receiving an oral examination to skin is normally sharply demarcated and detect not only dental and periodontal problems, homogenous in color and texture. Inspect but also to detect mucosal and other abnormali- and bimanually palpate the lip for surface ties, such as the rare instance of oral cancer. The changes or color irregularities (Fig. 9a). concept of self-examination may also be broached (ii) Labial mucosae: Reflect the lips to visualize with the patient, along with instructions of the the labial vestibule, and inspect/palpate for steps they can perform at home. This exam is any surface or submucosal abnormalities both visual and tactile (i.e., with palpation), and (Fig. 9b–d). patients should be asked to remove removable (iii) Gingivae: Inspect and palpate all gingival dental appliances, and to rinse out food particles. structures. Healthy gingivae should be Develop a consistent examination sequence, the pink, stippled, nonedematous, and have order of which is not that important, as long as all knife-edged interdental papillae (Fig. 9e). elements are completed. An adequate light source (iv) Buccal mucosae: Retract this tissue digi- is critical to the intraoral examination. A standard tally or with a mouth mirror to inspect/pal- overhead halogen dental light or, preferably, a pate all aspects of the buccal mucosae, Clinical Evaluation of Oral Diseases 17

Fig. 7 (a) Boundaries of the posterior triangle of the neck. (b) Palpation of the posterior triangle

including the posterior aspects of the buccal number of specialized papillae, namely a vestibules. Palpate the parotid extraorally row of round pink mildly elevated circum- to evaluate salivary flow through the vallate papillae dotted in a V-distribution at Stenson’s duct orifice (Fig. 9f). the posterior border of the oral tongue; (v) Tongue: The tongue is divided into the small red fungiform papillae distributed “oral tongue” (the anterior 2/3rd) and the throughout the dorsal surface (and often base of tongue (the posterior 1/3rd). The concentrated at the tip of the tongue); and oral tongue is comprised of the dorsal, lat- most commonly the tiny fingerlike eral, and ventral surfaces, which are ame- keratinized filiform papillae. The foliate, nable to inspection and palpation. A piece circumvallate and fungiform papillae of gauze may be wrapped around the house taste buds. The ventral tongue has a tongue to allow access to the posterior thin mucosal lining contiguous with the aspects of the dorsum and posterolateral floor of mouth, contains a midline frenum, border of the tongue where the foliate papil- plica frimbriata lateral to the frenum, and lae and lymphoid tissues may be inspected/ one may observe the deep lingual veins palpated and compared bilaterally (Fig. 9j). The posterior 1/3rd of the tongue (Fig. 9g–i). The dorsal tongue harbors a is more difficult to visualize directly; 18 C.N. Idahosa and A.R. Kerr

Fig. 8 (a) Boundaries of submandibular/submental triangles. (b) Palpation of the superficial submandibular lymph nodes. (c) Palpation of the submental nodes

however, it should be palpated and/or visu- (viii) Oropharynx: The oropharynx comprises alized indirectly by mirror or endoscopy the soft palate, the uvula, anterior and pos- gag reflex permitting (Fig. 9n, o). terior pillars (or fauces), the posterior pha- (vi) Floor of mouth: Since abnormal surface ryngeal wall, the palatine tonsils, and base changes may be subtle, air-drying this of tongue (Fig. 9m). These structures, along region facilitates examination. The sublin- with the nasopharyngeal and lingual tonsils gual caruncles or sublingual papillae are comprise Waldeyer’s ring, part of the two small round structures found either mucosal immune system. A tongue blade side of the frenum, and these house or mouth mirror may be used to depress the Wharton’s duct openings. Fanning out lat- tongue. This is the opportunity to assess erally from these papillae are elevated sub- cranial nerves IX and X by provoking a lingual folds containing the openings from gag reflex and having the patient say the sublingual glands (Fig. 9k). Bimanual “aahh” and watch the even elevation of palpation of the floor of mouth should be the soft palate. The retromolar trigone is performed by gently moving two opposing the area distal to the mandibular retromolar fingers, one extraorally and the other pad and this should be part of the examina- intraorally, from posterior to anterior, softly tion. The palatine tonsils sit in the tonsillar palpating the interposing soft tissue fossae between the pillars. It is important to (Fig. 9p). record their presence (many patients have (vii) Hard palate: Inspection and palpation of the had them surgically removed), color, and hard palate is important. Small mucosal symmetry. The base of tongue contains the swellings are easy to miss when the exam- lingual tonsils. iner relies on inspection alone (Fig. 9l). Clinical Evaluation of Oral Diseases 19

Fig. 9 Soft Tissue Examination: (a) Lips, (b) Lower labial tissue, (j) Ventral surface of tongue, (k) Floor of mouth, mucosa/vestibule, (c) Palpation of lower lip, (d) Upper (l) Palpation of hard palate, (m) Oropharynx, (n) Indirect labial mucosa/vestibule, (e) Gingivae, (f) Buccal mucosa, inspection of base of tongue, (o) Palpation of base of (g) Dorsal tongue, (h) Lateral border of tongue, (i) Pos- tongue, (p) Bimanual palpation of the floor of mouth terolateral tongue showing foliate papillae/lymphoid 20 C.N. Idahosa and A.R. Kerr

(ix) Dentition: A detailed description of the although a reduction or absence of saliva examination of the teeth and supporting may not necessarily be associated with true structures to detect common dental diseases salivary gland hypofunction (e.g., dehydra- (i.e., caries and periodontal disease) is tion). Other signs of normal salivary flow beyond the scope of this book. However, may include a glistening of mucosal sur- the state of the dentition can provide faces commensurate with adequate saliva insights about the overall health of the and the presence of salivary pooling in the patient, and a careful examination of the floor of the mouth. Clinicians should also dentition to detect dental abnormalities look for signs of salivary dysfunction (see beyond caries, periodontitis, odontogenic chapter on Salivary Gland Disorders and infections, and occlusal/jaw discrepancies Diseases). (i.e., that might typically be managed ortho- The gold standard for the assessment of dontically) is warranted. Examples are den- normal salivary gland function is by tal erosion, disorders of enamel or dentin sialometry, measuring the quantity and formation, intrinsic or extrinsic discolor- quality of saliva generated by the glands ation (e.g., secondary to tetracycline use). in both the basal (unstimulated) state and Deviations from the normal tooth number, during stimulation, either by measuring the shape, color, eruption patterns, and occlu- collective secretions from all the glands sion offer the initial clues. The involvement (i.e., whole saliva) or by measuring saliva may be restricted to a single tooth, multiple from each gland individually. Ideally, teeth, or be generalized to the entire denti- sialometry should be performed during a tion. These clues provide the basis for fur- morning appointment with the patient ther probing of the patient’s history, instructed not to eat or drink (except water including family history (e.g., where a as needed) for 90 min before the appoint- hereditary disease, such as amelogenesis ment. With the patient in a relaxed state and imperfecta, might be suspected). The clini- in a quiet environment, the procedures of cal examination may need to be saliva collection should be clearly supplemented with radiographs (or other explained to the patient. Sitting in an diagnostic testing) to further characterize upright position, the patient should be the abnormalities. Clinicians should also instructed to swallow their saliva, tilt their assess the relationship of teeth to the sur- head forward, and place a preweighed rounding mucosae. Broken and sharp teeth, collecting tube next to their mouth restorations, or dentures can lead to fric- (Navazesh et al. 2008). Setting the timer tional keratosis or traumatic ulcers. Large for 5 min or more, they should allow saliva amalgam restorations can cause local to drool out of their mouth into the tube. At lichenoid reactions of the adjacent mucosa. the end of the time, they should expectorate (x) Saliva: Salivary gland function may be all residual saliva into the tube. The tube crudely assessed by identifying the gland should be weighed to calculate the weight openings intraorally (Stenson’s ducts from of saliva and the value divided by the num- the parotid glands open on the buccal ber of minutes collected to generate a flow mucosae near the maxillary 2nd molar, rate. One gram is equivalent to 1 mL of and Wharton’s ducts emanate from the sub- saliva and mean normal unstimulated flow lingual caruncles in the floor of mouth), and rates are 0.3–0.4 mL/min. Stimulated sali- then “milking” each gland and observing vary flow rates are performed if a patient saliva secretion. The presence, consistency/ has an abnormally low unstimulated flow viscosity (normal viscosity versus thick/ rate (i.e., <0.2 mL/min) and may be mea- stringy, or bubbly), and color of the saliva sured by a number of techniques including (clear versus turbid) may be recorded, asking the patient to chew a flavorless gum Clinical Evaluation of Oral Diseases 21

base, paraffin wax, or a sugarless lemon (alternatively, a miniature hand chart may drop for 5 min, expectorating every 30 s be used) and asked to cover one eye and during collection. The mean normal stimu- then read the smallest line of print possible. lated flow rate is 1–2 ml/min. In patients Visual acuity is expressed as two numbers suspected to have dental erosion, salivary (e.g., 20/40). The first is the distance from pH and buffering capacity can also be the patient to the chart, and the second is the undertaken using commercially available distance at which the patient’s eye can read kits (e.g., GC Saliva Check, GC Corpora- the line of the smallest numbers. Visual tion, Japan). fields may also be assessed via confronta- Sialometry to measure individual gland tion testing, usually by the static finger secretions, to detect salivary pH, buffering wiggle test and the kinetic red target test. capacity, and composition is also possible, Pupillary reactions are mediated by CNs II although not routinely performed outside of and III (see below). a research setting. (iii) Oculomotor nerve (CN III): The pupillary (xi) Screening adjunctive techniques: These are reflex (also mediated by CN II) may be defined as techniques that are applied to assessed through two reactions: the light patients during an examination to provide reaction and the near reaction. The light additional information about the patient or reaction is assessed by shining a light into a specific abnormality detected (e.g., the one eye which should lead to pupillary con- use of light-based visualization techniques striction in both eyes (the light is sensed by such as tissue autofluorescence devices to the retina, which stimulates the optic nerve, screen for malignant and potentially malig- and then impulses are sent from the brain nant disorders). This is covered in more back via CN III to cause the pupil to con- detail in the chapter on Oral Mucosal strict (i.e., iris muscle dilation). The near Malignancies. reaction is when the patient is asked to focus their gaze on an object, such as a Cranial nerve examination: There are 12 cra- finger placed equidistant from both eyes, nial nerves (CN), although routine assessment of that is brought closer and leads to pupillary every cranial nerve is not typically indicated. Oral constriction (i.e., accommodation). CN III health-care providers will routinely test cranial also provides motor innervation to most of nerves V, VII, IX, X, and XII during a routine the extraocular muscles (i.e., all except the examination. The others may be tested when there lateral rectus and superior oblique mus- is an indication. cles), along with the levator palpebrae superioris muscles (to elevate the upper (i) Olfactory nerve (CN I): The sense of smell eyelid). may be tested using familiar inoffensive (iv) Trochlear nerve (CN IV): This nerve pro- odors, such as soap. First assess the patency vides motor innervation to the superior of each nasal passage by asking the patient oblique muscle and is assessed along with to occlude one side and then breath through CNs III and VI by instructing the patient to the open passage of the other side. If both follow the six extraocular movements (i.e., are patent, ask the patient to close their an “H” shape made by a finger or pencil): eyes, occlude one nostril at a time and all the way to one side, then up and down, sniff the smell of the selected substance. then all the way to the other side, then up Ask them to name the substance and test and down. both sides. (v) Trigeminal nerve (CN V): This nerve has (ii) Optic nerve (CN II): Visual acuity may be three divisions, two of which are sensory tested using a Snellen chart. Patients are (V1: ophthalmic and V2: maxillary) and positioned 20 feet from the chart one which is both sensory and motor (V3: 22 C.N. Idahosa and A.R. Kerr

mandibular). The sensory nerves may be bone conduction, and the Weber test for assessed by having the patient close their lateralization). Assessment of the vestibular eyes and then lightly touching the facial system is rarely performed as part of the skin distribution, on both sides, of the routine cranial nerve examination. three sensory branches. Then, perform the (ix) Glossopharyngeal nerve (CN IX): Visceral same steps with a pin or sharp object. Ask functions aside, this nerve provides motor the patient to tell you where they feel the innervation to the stylopharyngeus muscle sensation, and the type of sensation (soft which helps elevate the pharynx and lar- touch or sharp prick), comparing sides. ynx, and provides sensation to the posterior The corneal reflex (V1) may be assessed oral cavity including taste sensation from by touching the cornea with a wisp of cot- the posterior third of the tongue. It is usu- ton and observing a blink. Motor branches ally assessed by testing the gag reflex, by to the muscles of mastication may be placing a tongue depressor onto the poste- assessed by asking the patient to clench rior aspect of the tongue; however, absence their jaws and observing bilateral contrac- of a gag reflex does not assure a tion of the masseters and temporalis mus- glossopharyngeal nerve palsy. cles. The patient’s ability to perform (x) Vagus nerve (CN X): The vagus provides symmetric jaw movements (opening, clos- motor innervation to other pharyngeal and ing, lateral, and protrusive jaw movements) laryngeal muscles, along with fibers to the may be assessed too. heart, thoracic, and abdominal viscera. It (vi) Abducens nerve (CN VI): This nerve pro- may be assessed in conjunction with CN vides motor innervation to the lateral rectus IX by asking the patient to say “ah” and ocular muscle, and assessment is similar to watching the symmetric elevation of the that of CNs II and IV. soft palate and uvula. (vii) Facial nerve (CN VII): This nerve provides (xi) Spinal accessory nerve (CN XI): This is a motor innervation to the muscles of facial motor nerve to the sternocleidomastoid expression and also carries taste and other (SCM) and trapezius muscles. The SCMs sensory neurons. The motor portion may be may be assessed asking the patient to turn assessed by asking patients to perform a their head against the force of your hand, number of facial grimaces, such as wrin- and the trapezius muscles may be assessed kling their forehead (contracting the by the shrugging the shoulders against frontalis muscles), tightly contracting the force. Look for symmetrical strength. eyelids (orbicularis oculi), or smiling and (xii) Hypoglossal nerve (CN XII): This nerve showing the teeth (orbicularis oris). Look provides motor innervation to the intrinsic for symmetry. and extrinsic tongue muscles. Look for (viii) Vestibulocochlear nerve (CN VIII): Audi- symmetry at rest and then ask the patient tory acuity may be simply assessed by the to protrude their tongue. Fasciculation of whispered voice test. Standing behind the the tongue or deviation may indicate an patient so they cannot see the lips of the ipsilateral CN XII palsy. examiner, simultaneously occlude the non- test ear and gently rub its external meatus, Vital signs: Oral health-care providers should then exhale completely and then whisper be able to perform vital signs on all patients; this three random numbers from 6 inches includes blood pressure, heart rate and rhythm, away. Ask the patient to repeat the numbers respiration, temperature, and others. and repeat on the other ear. For patients who fail this test, a tuning fork may be (i) Blood pressure: Blood pressure is typically used to assess neurosensory and conductive measured chairside using a sphygmoma- hearing loss (i.e., the Rinne test for air and nometer and stethoscope and is technique Clinical Evaluation of Oral Diseases 23

Fig. 10 (a) Palpation to identify brachial artery. (b) Placement of cuff and bell of stethoscope. (c) Palpation to identify radial artery

sensitive. Either arm may be selected (unless pharmacotherapy (Grade A evidence) one arm has an A-V shunt for dialysis, or has (James et al. 2014). There are a number of lymphedema secondary to a breast mastec- scenarios leading to false positive (e.g., tomy), but the arm should be free of any white coat hypertension, or recent coffee clothing. The brachial artery should be pal- intake) or false negative (e.g., orthostatic pated for a pulse (Fig. 10a) and the arm lifted hypotension) blood pressures in a clinical so that the antecubital crease is at heart setting. Serial ambulatory or home blood height, then the inflatable cuff is centered pressure testing will provide more predict- over the artery, positioned above the crease. able readings. Blood pressure readings in Inflate the cuff until the radial pulse is elim- excess of 180 mg Hg systolic or ! inated and check the blood pressure reading. 110 mg Hg diastolic are suggestive of a ! Deflate the cuff, place the bell-side of the hypertensive urgency, regardless of the pres- stethoscope over the brachial artery, and ence of associated signs and symptoms such reinflate to a pressure 30 mg Hg above the as headache, nosebleeds, severe anxiety, or previous inflation value, and slowly deflate shortness of breath. Such patients require a the cuff listening for two sets of sounds more detailed examination to rule out under- (Fig. 10b): the pressure at which the sounds lying systemic diseases (e.g., renal disease). are initially heard is the systolic pressure, (ii) Heart rate and rhythm: The radial artery is and the pressure when the sounds are typically chosen to assess this, and the clini- completely lost is the diastolic pressure. cian should place the pads of both the middle Blood pressure is calculated from the aver- and index fingers just proximal to the wrist age of two readings (one on each arm). with sufficient pressure to detect the pulse A threshold blood pressure reading of (Fig. 10c). Assess the rhythm first, and if 90 mg Hg diastolic in an adult aged regular, count the pulse for 30 s then multiply 30! –59 years or readings of either 150 mg the value by 2. The normal range is 50–90 ! Hg systolic or 90 mg Hg diastolic in adults beats/min and if the rate is abnormally high ! >60 years is indicative of hypertension and a (tachycardia) or low (bradycardia), measure strong recommendation for initiation of again for a full 60 s. If the rhythm is irregular, 24 C.N. Idahosa and A.R. Kerr

attempt to detect a pattern. Irregular rhythm, patients. It is important for radiographs to show tachycardia, or bradycardia typically will the full extent of all lesions captured. Key findings indicate further cardiac testing (e.g., electro- that should be put into consideration when cardiography) to identify the underlying interpreting jaw lesions include: location, number etiology. of lesions, shape, border characteristics, dimen- (iii) Respiration: The rate, rhythm, and depth of sion, internal structure, cortical expansion, and breathing may be observed over a 60-s effect on adjacent structures/teeth. Imaging period. A regular rhythm of approximately modalities utilized in the head and neck region 20 breaths is normal. include the following: (iv) Temperature: An average normal oral tem- Photography and videography in oral medi- perature is 37 C (98.6 F), yet it can fluctu- cine: The documentation of examination abnor- ate to as low as 35.8 C (96.4 F) in the early malities, typically by digital photography, serves a morning or to as high as 37.3 C (99.1 F) in number of important functions. Firstly, images the evening. The oral temperature is serve as a baseline record of the initial presenta- performed preferably by an electronic ther- tion of an abnormality that may be used for diag- mometer with the tip placed under the tongue nosis, to communicate with colleagues who are and with the lips closed. part of the patient’s care, as part of a scientific (v) Other vital signs: Pain assessment is consid- publication, or for the purpose of comparison over ered a vital sign in most medical settings. a number of follow-up visits (e.g., to gauge There are a number of validated pain assess- response to treatment). Secondly, images can be ment tools available (see the chapter on clin- used for patient education and may be sent to ical evaluation of orofacial pain). Pulse patients for their own records. Thirdly, images oximetry is also considered a vital sign. It is serve as part of the patient’s record. They “speak a surrogate measure for arterial blood oxy- a thousand words” and can be useful from a med- gen saturation and normal values are >90%. icolegal standpoint. Videography may also be useful to convey abnormal examination findings, such as a cranial nerve palsy or recording a pro- Imaging cedure. There is a dizzying array of digital camera systems available to clinicians that range in cost Imaging studies, discussed in greater detail in the and image output. Smart phones have become chapter on Diagnostic Imaging Principles and popular in medical photography for their simplic- Applications in Head and Neck Pathology, are ity, good image resolution, and ease of sharing important diagnostic tools. In addition to radio- images. Sophisticated digital cameras with macro- graphic and other imaging modalities (i.e., mag- lenses and ring flash systems are expensive, netic resonance imaging (MRI)), this section will although they produce images suitable for publi- include digital photography and videography. cation quality, with excellent resolution and the Because most radiographs utilized by oral ability to capture focused images of intraoral health-care providers carry the risk of radiation abnormalities with variable depth of field. Before exposure, they should be carefully selected (Far- taking images, the patient should provide written man 2005). The choice of an imaging modality consent that covers all issues related to patient should therefore be based upon its ability to con- privacy, although these requirements may vary tribute to diagnosis and management and not on depending on local regulations. Patient positioning its availability. In addition to dental disease, radio- and the use of oral retractors will greatly facilitate graphs should be ordered to visualize the bone the capture of quality images. The storage of underlying soft tissue lesions, for intraosseous images is also an important issue. If an electronic pathology, trauma and suspected fractures, sali- health record is being used, images should be vary gland disorders, TMJ pain, and dysfunction uploaded as part of the patient’s record. If this is and to rule out intracranial lesions in specific not feasible, images should be labeled with the Clinical Evaluation of Oral Diseases 25 date, and patient’s name and chart number on an well as positron emission tomography (PET) uti- encrypted computer or other storage device. lized for detection and monitoring of Plain films: Traditional dental radiographs malignancies. include bitewings, periapicals, occlusal, and pan- oramic radiographs. Bitewing radiographs are particularly useful for visualizing interproximal Diagnosis caries. Intraoral periapical radiographs are useful for imaging the dentition and supporting struc- Abnormal findings: Abnormal clinical features tures while occlusal radiographs of the maxilla (i.e., symptoms and signs) should be accurately and mandible are utilized for visualizing the palate described and recorded. This disciplined process and floor of the mouth, respectively. Panoramic of accurately describing clinical features will radiographs are useful for gross evaluation of greatly facilitate the diagnostic process and intraosseous lesions of the maxilla and mandible allow effective communication of findings with and the TMJ. Other maxillofacial radiographs colleagues. It is helpful to develop a vocabulary of may also be prescribed depending on the specific descriptors for the myriad of signs and symptoms needs of the patient such as the occipitomental patients may present with. As an example, oral (Waters) skull projection used for visualization lesions may be described by symptoms such as the of the maxillary sinuses. sensation of a surface change or a growth, pain, Computed tomography (CT): CTs are asso- fever, malaise, burning, sensitivity to acidic or ciated with a higher radiation dose compared with spicy foods or beverages, taste changes, numb- plain films but provide better anatomic details of ness, oral dryness, inability to chew, tooth mobil- the hard tissues. With the utilization of contrast ity, bleeding, and others. Signs such as color, media, soft tissue structures can also be visual- shape, number, location/distribution, symmetry, ized. In the maxillofacial region, they are useful surface topographical features, margin definition, for evaluating the extent of maxillary and man- size, and tactile consistency of oral soft tissue dibular cysts and tumors, salivary gland pathol- lesions as well as the presence or absence of ogy, fascial space infections of the head and neck, regional lymph nodes should be recorded. and cervical lymph node involvement in head and Table 6 provides a list of physical descriptors neck cancer patients. Cone beam CT (CBCT) pro- commonly applied to oral mucosal lesions. Simi- vides reduced radiation exposure compared with larly, for bone diseases/jaw lesions, the following CT and is the imaging modality of choice for nonradiographic features should be described and visualizing hard tissue structures when a limited noted: asymmetry/bony expansion, palpation of field of the head and neck is to be evaluated. cortex (bony hard, soft, egg shell), presence of Magnetic resonance imaging (MRI): bruit, tooth mobility, and displacement. Radio- Although expensive, MRIs have no associated graphic features include: size; number, both single radiation exposure and are excellent for visualiza- versus multifocal and localized versus general- tion of soft tissues. In the maxillofacial region, ized; position in the jaws; characteristics of lesion they are indicated for evaluation of the articular border/periphery such as well-defined versus disc and other soft tissue components of the TMJ, poorly defined, punched-out, corticated, sclerotic; neoplasms, and salivary glands and to rule-out shape (e.g., circular, scalloped); internal structures intracranial lesions in specific subsets of orofacial such as radiolucent, radio-opaque, mixed pain patients such as those presenting with cranial radiolucent/radio-opaque, multilocular with or nerve abnormalities or trigeminal neuralgia. without septae; and changes in trabecular patterns Other imaging modalities utilized in the max- or the presence of dystrophic calcifications and illofacial region include ultrasonography and tooth-like structures. sialography for evaluation of salivary glands as 26 C.N. Idahosa and A.R. Kerr

Table 6 Descriptive terminology for oral lesions Term Definition Abscess Localized collection of purulent exudate Atrophy Loss of tissue resulting in thinning of the epithelium and usually associated with erythema Bulla Fluid filled elevated lesion >5 mm in diameter Ecchymosis Red/purple macular area of submucosal hemorrhage/extravasated blood Endophytic A lesion that is growing inwards into the underlying tissue Erosion Partial loss of the surface epithelium not extending through the full thickness Erythema Redness of the mucosa usually caused by inflammation, atrophy of capillary dilatation Exophytic A lesion that grows outwards from the surface epithelium Fissure Linear slit or groove in the skin or mucosa Fistula Abnormal tract connecting two body cavities Fixed A lesion that is firmly attached to the overlying or underlying structures Hematoma A localized swelling filled with blood Indurated Hardening of soft tissue usually due to chronic inflammation or malignancy Macule Circumscribed discolored flat lesion not raised above level of surrounding mucosa Mobile A lesion that is freely movable and not attached to the overlying or underlying structures Nodule Circumscribed elevated solid lesion >5 mm in diameter Papillary A lesion that has numerous surface projections Papule Circumscribed elevated solid lesion <5 mm in diameter Pedunculated Exophytic lesion attached to the underlying tissue by a stalk Petechiae Pin-point red or purple spots caused by submucosal hemorrhage Plaque Slightly elevated area of mucosa with a flat surface Pustule Circumscribed raised lesion containing pus Reticular Resembling a net Sessile Exophytic lesion attached to the underlying tissue by a broad base Ulcer Break in continuity of the oral mucosa due to loss of full thickness of oral epithelium resulting in exposure of underlying connective tissue which is usually coated by a white or yellow membrane Verrucous An exophytic lesion with rough wartlike projections Vesicle Fluid filled elevated lesion <5 mm in diameter

Categories/classification systems of oral dis- (Table 8), location (Table 9), or clinical behavior eases: Oral and maxillofacial diseases encompass (Table 10). These classification systems can facil- a wide variety of disorders with different etiolo- itate the process of narrowing down a list of pos- gies and pathogenesis. It is always a challenge to sible diseases while formulating a differential adequately fit diseases into classification systems, diagnosis. Hard tissue diseases/jaw lesions are and overlap is inevitable. Oral and maxillofacial typically classified by their radiographic features, diseases are initially grouped by their primary such as radiolucent (Table 11) versus radio- clinical features, such as soft tissue versus hard opaque or mixed lesions (Table 12). tissue/bone diseases, orofacial pain, temporoman- Differential diagnosis: Effective management dibular disorders, salivary gland dysfunction of patients with oral and maxillofacial diseases (hypofunction versus sialorrhea), neurosensory hinges on the ability of the oral health-care pro- disorders (halitosis, taste changes, dysesthesias), vider to arrive at an accurate diagnosis. For some movement disorders, dental anomalies, and sub- diseases, a clinical diagnosis that can be made sequently each group branches into classification based on the pathognomonic appearance of a trees based on a myriad of different features. lesion (e.g., fluid-filled vesicles of recurrent her- As an example, the group of soft tissue dis- pes labialis) is equivalent to the definitive diagno- eases may be classified based on underlying dis- sis. However, other diagnoses are more elusive, ease process (Table 7), clinical appearance and the clinician may not be able to single out a Clinical Evaluation of Oral Diseases 27

Table 7 Differential diagnosis of oral mucosal diseases based on etiology Infectious diseases Candidosis, herpes simplex virus infection, varicella zoster virus infection, coxsackie virus infections measles, oral hairy leukoplakia, tuberculosis, syphilis, human papillomavirus associated oral lesions, infectious mononucleosis Allergic, immune-mediated, and Pemphigus vulgaris, mucous membrane pemphigoid, linear IgA disease, autoimmune diseases aphthous stomatitis, Behçet syndrome, erythema multiforme, oral lichen planus, lupus erythematosus, graft-versus-host disease, orofacial granulomatosis Malignant and potentially malignant Actinic cheilitis, leukoplakia, erythroplakia, erythroleukoplakia, oral disorders submucous fibrosis, salivary gland malignancies, oral melanoma, verrucous carcinoma and oral squamous cell carcinoma Reactive lesions Traumatic ulcerations, frictional keratosis, linear alba, nicotinic stomatitis, focal fibrous hyperplasia, chemical and thermal burns Hereditary conditions White sponge nevus, epidermolysis bullosa

Table 8 Differential diagnosis of oral mucosal diseases based on clinical appearance White lesions that can be Pseudomembranous candidosis, chemical and thermal burns wiped off White lesions that cannot be Linear alba, morsicatio buccarum, leukoedema, white sponge nevus, oral hairy wiped off leukoplakia, leukoplakia, leukoedema oral lichen planus, lupus erythematosus, hyperplastic candidosis, frictional keratosis, smoker’s keratosis, and submucous fibrosis Red lesions Erythematous candidosis, denture associated erythematous stomatitis, irritational erythema from trauma and burns, submucosal hemorrhage, erythroplakia, linear gingivitis, plasma cell gingivitis, Kaposi sarcoma Mixed white/red lesions Candidosis, erosive lichen planus, geographic tongue/erythema migrans, systemic lupus erythematosus, contact and systemic allergic reactions, erythroleukoplakia Vesicular and ulcerated Aphthous stomatitis, ulcerative lichen planus, mucous membrane pemphigoid, lesions pemphigus vulgaris, erythema multiforme, linear IgA disease, epidermolysis bullosa, traumatic ulcers, herpes simplex virus infections, varicella zoster virus infections, coxsackie virus infections, tuberculosis, deep fungal infections, necrotizing sialometaplasia, syphilis, squamous cell carcinoma Submucosal bumps and Focal fibrous hyperplasia, mucocele, lipoma, angiogranuloma, peripheral ossifying lumps fibroma, peripheral giant cell granuloma, epulis fissuratum, parulis, sialolith, granular cell tumor, hemangioma, neurofibroma, other mesenchymal tumors, salivary gland neoplasms, squamous cell carcinoma Papillary and verrucous Squamous papilloma, verruca vulgaris, condyloma acuminatum, focal epithelial lesions hyperplasia, proliferative verrucous leukoplakia, verrucous carcinoma, verruciform xanthoma, verrucous leukoplakia, verrucous hyperplasia Pigmented lesions Physiologic pigmentation, amalgam tattoo, smoker’s melanosis, melanotic macule, melanocytic nevus, melanoacanthoma, Peutz Jeghers syndrome, Addison’s disease, oral melanoma diagnosis, but is able to generate a “shortlist” of incorporating many different entities. In contrast, possible diagnoses, known as the differential the experienced master clinician may have only diagnosis. This list of possible diagnoses is two or three entities listed. Thorough knowledge based on the patient’s history and physical exam- of human anatomy, pathophysiology, and clinical ination findings and is ranked in order from most behavior of oral and maxillofacial diseases is crit- likely to least likely. The diagnosis placed at the ical to ascertaining the correct diagnosis while top of a differential list is known as the working avoiding dangerous medical errors. Figures 11, diagnosis. For novices, the initial differential 12, 13, 14, and 15 outline differential diagnosis diagnosis may be fairly broad in scope 28 C.N. Idahosa and A.R. Kerr

Table 9 Differential diagnosis of oral mucosal diseases based on location Lip Fordyce granules, recurrent herpes labialis, actinic cheilitis, angular cheilitis, squamous cell carcinoma Labial mucosa Mucocele, epulis fissuratum, focal fibrous hyperplasia, salivary gland neoplasms, aphthous ulcers, other mesenchymal tumors Buccal mucosa Linear alba, leukoedema, pseudomembranous candidosis, Fordyce granules, aphthous ulcers, focal fibrous hyperplasia, lipoma, morsicatio buccarum, oral lichen planus, mucous membrane pemphigoid, pemphigus vulgaris, leukoplakia Hard palate Denture associated erythematous stomatitis, nicotinic stomatitis, thermal burn, inflammatory papillary hyperplasia, palatal abscess, recurrent intraoral herpes simplex infection, melanocytic nevus, necrotizing sialometaplasia, salivary gland neoplasms, lymphoma, Kaposi sarcoma, melanoma Soft palate Petechiae, viral papilloma, pseudomembranous candidosis Tonsils/oropharynx Tonsillitis, tonsiloliths, bifid uvula, viral papilloma, lymphoepithelial cyst, squamous cell carcinoma Tongue Hairy tongue, fissured tongue, hairy leukoplakia, erythema migrans, oral lichen planus, mucous membrane pemphigoid, pemphigus vulgaris, granular cell tumor, focal fibrous hyperplasia, neurofibroma, neurilemmoma, median rhomboid glossitis, atrophic glossitis, angiogranuloma, hemangioma, lymphangioma, proliferative, verrucous leukoplakia, squamous cell carcinoma Floor of mouth Ranula, sialolith, dermoid cyst, lymphoepithelial cyst, salivary gland neoplasms, squamous cell carcinoma Gingiva and alveolar Gingivitis, oral lichen planus, recurrent intraoral herpes simplex infection, herpes zoster, process mucous membrane pemphigoid, pemphigus vulgaris, gingival overgrowth, parulis, acute necrotizing ulcerative gingivitis, primary herpetic gingivostomatitis, angiogranuloma, peripheral giant cell granuloma, peripheral ossifying fibroma, pericoronitis, epulis fissuratum, leukemic infiltrates, Kaposi sarcoma, metastatic tumors

Table 10 Differential diagnosis of ulcerative mucosal diseases based on clinical behavior Localized acute vesicular and/or Aphthous ulcer, traumatic ulcer, necrotizing sialometaplasia, recurrent herpes ulcerative lesions labialis, recurrent intraoral herpes, syphilitic chancre, anesthetic necrosis Localized chronic vesicular and/or Traumatic ulcerative granuloma with stromal eosinophilia, squamous cell ulcerative lesions carcinoma, deep fungal infections, tuberculous ulcers Multiple acute vesicular and/or Erythema multiforme, primary herpetic gingivostomatitis, allergic reactions, ulcerative lesions varicella zoster infections (chicken pox and shingles), coxsackie virus infections Multiple chronic vesicular and/or Oral lichen planus, mucous membrane pemphigoid, pemphigus vulgaris, linear ulcerative lesions IgA disease, Behçet syndrome, lupus erythematosus, epidermolysis bullosa, graft-versus-host disease, Wegener’s granulomatosis

Table 11 Differential diagnosis of radiolucent jaw lesions Single unilocular Apical abscess, periapical granuloma, periapical cyst, periapical scar, focal cemento-osseous periapical dysplasia (early stage), cementoblastoma (early stage) Single unilocular Hyperplastic follicle, eruption cyst, dentigerous cyst, unicystic ameloblastoma, odontogenic pericoronal keratocyst, ameloblastic fibroma, adenomatoid odontogenic tumor, calcifying odontogenic cyst Multilocular Odontogenic myxoma, ameloblastoma, central giant cell granuloma, hemangioma, odontogenic keratocysyt, cherubism, brown tumor of hyperparathyroidism, ameloblastic fibroma Irregular or ill-defined Rarefying osteitis, osteomyelitis, MRONJ, osteoradionecrosis, osteosarcoma, chondrosarcoma, other primary malignancies, metastasis Multifocal Florid cement-osseous dysplasia (early stage), multiple myeloma, Gorlin syndrome, Langerhans cell disease, cherubism, hyperparathyroidism MRONJ Medication-related osteonecrosis of the jaw Clinical Evaluation of Oral Diseases 29

Table 12 Differential diagnosis of radiopaque and mixed jaw lesions Well-defined apical lesions Retained roots, condensing osteitis, idiopathic osteosclerosis, cementoblastoma, focal cemento-osseous dysplasia, periapical cemento-osseous dysplasia Well-defined lesions: Other Torus, exostosis, idiopathic osteosclerosis, odontoma, osteoma, central ossifying locations fibroma, calcifying odontogenic cyst, calcifying epithelial odontogenic tumor, adenomatoid odontogenic tumor, ameloblastic fibro-odontoma Irregular or ill-defined Osteomyelitis, MRONJ, osteoradionecrosis, cemento-osseous dysplasia, fibrous dysplasia, osteosarcoma, chondrosarcoma, squamous cell carcinoma, metastatic carcinoma Multifocal Craniofacial fibrous dysplasia, florid cemento-osseous dysplasia, MRONJ, Paget’s disease, Gardner’s syndrome, osteopetrosis MRONJ Medication-related osteonecrosis of the jaw

Ulcerative lesions Ulcerative lesion(s)

Persistent (> 2 weeks)

No Yes

Acute traumatic Aphthous ulcer(s) Viral etiology Erythema • mechanical • recurrent aphthous stomatitis • HSV multiforme • thermal (minor/herpetiform) • VZV • chemical • hematinic deficiencies • CMV • celiac disease • Coxsackie • Behcet’s • PFAPA

Chronic traumatic Aphthous-like ulcer(s) Vesiculobullous disorders Neoplastic • TUG/TUGSE • Crohn’s disease • pemphigus • SCC • ulcerative colitis • pemphigoid • lymphoma • orofacial granulomatosis • linear IgA disease • salivary gland • neutropenia • epidermolysis bullosa

Aphthous ulcer(s) Bacterial or Lichen planus • major fungal etiology or allergic reaction HSV: Herpes Simplex Virus VZV: Varicella Zoster Virus CMV: Cytomegalovirus SCC: Squamous cell carcinoma PFAPA: Periodic fever, aphthous stomatitis, pharyngitis, adenitis syndrome TUGSE: Traumatic ulcerative granuloma with stromal eosinophilia

Fig. 11 Algorithm for ulcerative lesions 30 C.N. Idahosa and A.R. Kerr

Pigmented lesions Pigmented lesions

Generalized

Yes No

Racial Reactive: Syndromes/ • tobacco (smoking) Systemic Diseases: • post-inflammatory • Peutz-Jeghers • drugs • Laugier-Hunziker • hormonal • Addison Disease

Amalgam Melanotic Intraoral Melanoacanthoma Malignant tattoo macule nevus • melanoma

Fig. 12 Algorithm for pigmented lesions algorithms for ulcerative, pigmented, white, red, provide additional information about the and exophytic soft tissue lesions. nature of the lesion. A number of diagnostic Definitive diagnosis: The definitive diagnosis adjuncts may have utility in the characteriza- is based on the result of a gold standard test for tion of potentially malignant disorders (e.g., diagnosing a particular disease such as histopa- light-based adjuncts, vital staining with tolu- thology to diagnose a squamous cell carcinoma. idine blue, cytopathogical platforms, and sal- In many situations, arriving at an accurate defini- ivary techniques) and a more detailed tive diagnosis from the differential diagnosis will description about these adjuncts, their indi- necessitate an analytic process involving gather- cations and accuracy will be covered in the ing additional clinical information from tests and chapter on Oral Mucosal Malignancies. The investigations. The choice of diagnostic tests is process of procuring cells from a lesion, based on the items in the differential diagnosis and typically from the lesion surface, is known the most appropriate tests should be chosen based as exfoliative cytology. Conditions amena- on test accuracy. Types of investigations neces- ble to exfoliative cytology are candidosis sary to determine a diagnosis may be in the form and possibly herpes simplex infections. of imaging studies, chairside diagnostic adjuncts, Identified lesions may be sampled by scrap- laboratory studies, and biopsy/histopathological ing the surface with a metal spatula or cotton studies. Data from the investigations are then cor- swab (i.e., a mucosal smear), plated on a related with the clinical findings before the final glass slide, immediately fixed, and sent to a diagnosis is rendered. The management of the pathology laboratory for staining and micro- patient is based on the definitive diagnosis; there- scopic analysis. Lesions that are suspected to fore, it is imperative that the correct diagnosis is be caused by or associated with candidiasis, made. yet not overtly obvious based on clinical features alone (e.g., erythematous (i) Diagnostic adjuncts: Diagnostic adjuncts are candidosis), are indicated for a mucosal applied to an identified lesion or lesions to smear and candidal hyphae may be Clinical Evaluation of Oral Diseases 31

White Lesions or lesions with predominant white component

White lesions

Does lesion rub away

Yes No

Infections etiology Reactive etiology • pseudomembranous • thermal or chemical candidosis • allergy • mechanical trauma

No apparent cause Keratosis Infectious etiology • hereditary • hairy leukoplakia Striae eg white • HPV-related sponge • hyperplastic candidosis Leukoplakia: rule out nevus dysplasia or carcinoma • frictional • hyperkeratosis or • tobacco Classic reticular striae Atypical striae hyperplasia • lichen planus • Lupus erythematosus • dysplasia • lichenoid mucositis • GVHD • carcinoma in situ • squamous cell carcinoma

Fig. 13 Algorithm for white lesions or lesions with a predominant white component

confirmed by periodic acid-Schiff staining, histopathologic diagnosis. Performing a or in the office by a potassium hydroxide biopsy of soft tissue lesions requires minimal float. surgical expertise; however, selecting the (ii) Laboratory investigations: These include biopsy site that will optimally provide repre- microbiological testing (i.e., standard culture sentative tissue requires careful consider- techniques, or by detecting microbial anti- ation because different diseases dictate gens, antibodies and other immune reac- different sampling techniques. Excisional tions, or by newer molecular techniques biopsy is performed when the intent is to (e.g., 15 s ribosomal RNA)), and bloodwork remove an entire lesion, while incisional (e.g., complete blood counts, metabolic biopsy is indicated when a representative panels, serological analyses). These investi- part of a lesion is taken. The tissue sample gations are covered in the chapters on Labo- should be immediately placed into a bottle ratory Medicine and Diagnostic Pathology, containing formalin or other appropriate and Clinical Immunology in Diagnoses of solutions depending on the investigation Maxillofacial Disease. required and transported to the pathology (iii) Biopsy and histopathological investigation: laboratory along with a requisition form The definitive diagnosis of many oral and that describes the patient demographics, his- maxillofacial diseases is based on a tory, and physical findings including the site 32 C.N. Idahosa and A.R. Kerr

Red Lesions or lesions with a predominant red component

Red lesions

Widespread

Yes No

Vesiculobullous Fungal Nutritional Other • pemphigus • erythematous deficiency • erythema migrans • pemphigoid candidosis • iron • vascular lesions Immune-mediated • folate • lichen planus • vitamin B12

Center of tongue Bilateral corners of mouth Other • median rhomboid • angular cheilitis • vascular lesion (s) glossitis No apparent cause

Erythroplakia: rule out Palate Gingival dysplasia or carcinoma • erythematous candidosis • plaque-associated gingivitis • dysplasia (denture stomatitis) • desquamative gingivitis • carcinoma in situ • allergy to denture material • plasma cell gingivitis • squamous cell carcinoma

Fig. 14 Algorithm for red lesions or lesions with a predominant red component

of biopsy, and a presumptive/differential or physical examination/vital signs finding that diagnosis. These techniques are covered in needs further evaluation (e.g., shortness of breath, the chapter on Soft and Hard Tissue Opera- pallor, or elevated blood pressure); or (4) when it tive Investigations in the Diagnosis of Oral is necessary to obtain reports of laboratory tests Disease. and other investigations required for diagnosis and management. At other times, it may be nec- essary to refer a patient for evaluation and man- Referral/Consultation agement of specific clinical problems when the patient’s treatment needs fall outside the treating It is imperative that oral health-care providers are doctor’s scope of practice. Examples include: competent in their ability to communicate and (1) patients with extraoral lesions; (2) patients collaborate with other members of the health- with oral and maxillofacial signs and symptoms care team to facilitate the provision of health suggestive of a systemic disease; and (3) patients care. Medical consultation may be initiated with requiring specialized interventions such as sur- a patient’s physician or other health-care profes- gery. It is preferable that referral and consultation sionals in the following scenarios: (1) the patient requests be made in writing in the form of a report. is a poor historian and the medical history is However, in certain situations, a phone call, or unclear or incomplete; (2) the patient has a severe text message may be more practical when it is medical condition which increases the risk of an necessary to obtain information immediately. In adverse event (e.g., recent myocardial infarction); such circumstances, the phone conversation and (3) the patient has an abnormal review of systems messages must be documented afterward. Clinical Evaluation of Oral Diseases 33

Exophytic Lesions Exophytic soft tissue lesion (s)

Multiple

No

Yes

HPV-related • viral papilloma Traumatic Reactive Gingival • condyloma • traumatic fibroma • angiogranuloma • verruca vulgaris • fibrous hyperplasia • peripheral giant cell fibroma • mucocele • peripheral ossifying fibroma • neuroma

Developmental Malignant Benign Neoplasm • lymphoepithelial cyst • salivary • neurogenic • lymphoma • lipoma • SCC • muscle-derived • sarcoma • vascular • minor salivary gland

HPV-related Others Neurogenic • HIV-associated • gingival overgrowth • neurofibromatosis • Hecks disease • AML • MEN 2b • Cowden’s syndrome • Tuberous sclerosis MEN 2b: Multiple endocrine neoplasia 2b SCC: Squamous cell carcinoma AML: Acute myelogenous leukemia

Fig. 15 Algorithm for exophytic soft tissue lesions

Table 13 lists the information for referral and consultation requests. Table 13 Information for referral and consultation requests When medical consultation with a patient’s physician is required prior to dental treatment or Patient’s full name, date of birth, address, phone number, and email surgery, it is important to communicate the details Referring doctor’s full name, title, address, phone of the planned procedure, anticipated amount of number, fax, and email blood loss if applicable and level of stress to the Description of the problem patient. These medical consultations are made to Relevant history and physical examination findings request additional information concerning the Differential diagnosis/definitive diagnosis if available patient that will aid in risk assessment and poten- Radiographs, laboratory tests, and investigations already tial modifications to treatment. Therefore, the final performed responsibility regarding the risk of treatment lies All treatment modalities that have been initiated or are anticipated with the oral health-care provider who must 34 C.N. Idahosa and A.R. Kerr carefully make the final treatment decisions and the medical history and physical examination. not the physician (Gary and Glick 2012). Thorough knowledge of the anatomy, physiology, and clinical behavior of oral diseases is essential to make the correct diagnosis. It is extremely Documentation important that oral health-care providers are appropriately trained in the diagnosis and man- Medical records provide information regarding agement of diseases affecting the maxillofacial the history of patients’ evaluation and treatment region. and can serve as useful evidence during lawsuits. Therefore, it is important to maintain accurate well-organized and complete records in a chrono- Cross-References logical order. In settings where paper-based health records are utilized, it is important to ensure that ▶ Clinical Evaluation of Orofacial pain all pages of the health record contain the patient’s ▶ Clinical Immunology in Diagnoses of Maxillo- name and identification number. All entries facial Disease should be legible, dated, and contain the author’s ▶ Diagnostic Imaging Principles and Applica- name and identification. Although there is no tions in Head and Neck Pathology generally accepted format for documentation of ▶ Head and Neck Malignancies clinical data, it is imperative to carefully record all ▶ Interface Between Oral and Systemic Health to aspects of the clinical history, physical examina- Interface Between Oral and Systemic Disease tion, diagnosis, and treatment plan at every patient ▶ Laboratory Medicine and Diagnostic Pathology encounter (Table 1). Other important components ▶ Odontogenic Pathology of the medical record, which should be filed in the ▶ Oral Mucosal Malignancies chart, include laboratory and imaging reports, ▶ Oral Ulcerative Lesions referral and consultation requests, informed con- ▶ Oral Vesicular and Bullous Lesions sent, operative notes, postoperative orders, email, ▶ Salivary Gland Disorders and Diseases text messages, and telephone conversations. ▶ Soft and Hard Tissue Operative Techniques in Patients with chronic oral diseases will return the Diagnosis of Oral Disease for follow-up evaluation and care. An abbreviated ▶ White and Red Lesions of the Oral Mucosa history is sufficient and the SOAP format is help- ful to update the patient’s history and examination findings since the last visit (subjective, objective, References assessment, and plan). “Subjective” refers to the history, “objective” refers to examination find- Couch ET, Chaffee BW, Gansky SA, Walsh MM. The ings, “assessment” is the diagnosis along with changing tobacco landscape: What dental professionals need to know. J Am Dent Assoc. 2016;147(7):561–9. the disposition of the patient relative to the diag- Degenhardt L, Hall W. Extent of illicit drug use and depen- nosis (e.g., lichen planus, significant improve- dence, and their contribution to the global burden of ment on topical steroids), and “plan” is the new disease. Lancet. 2012;379(9810):55–70. management plan. Farman AG. ALARA still applies. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100(4):395–7. Gary CJ, Glick M. Medical clearance: an issue of profes- sional autonomy, not a crutch. J Am Dent Assoc. Conclusion and Future Directions 2012;143(11):1180–1. James PA, Oparil S, Carter BL, Cushman WC, Dennison- Himmelfarb C, Handler J, et al. 2014 evidence-based The goal of clinically evaluating oral diseases is to guideline for the management of high blood pressure in arrive at a definitive diagnosis and provide effec- adults: report from the panel members appointed to the tive and safe treatment to patients. A careful and eighth joint National Committee (JNC 8). JAMA. systematic approach must be applied to gathering 2014;311(5):507–20. and interpreting the information collected during Clinical Evaluation of Oral Diseases 35

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