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Clinical Evaluation of Oral Diseases

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Clinical Evaluation of Oral Diseases 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
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