Clinical Evaluation of Oral Diseases

Abstract

Oral medicine is concerned with the diagnosis and nonsurgical management of medically related disorders of the oral and maxillofacial region, as well as the oral health management of medically compromised patients. Oral diseases have a wide range of clinical presentations and can manifest either as a local oral disease or as a sign of an underlying systemic condition. Therefore, oral health is a vital component of overall systemic health, and an oral lesion may in certain situations be the initial presentation of a systemic disorder. Consequently, it is imperative that oral healthcare providers and physicians are adequately trained to accurately diagnose and manage diseases affecting the oral and maxillofacial region. This chapter addresses the systematic approach required for the evaluation of patients who present with oral diseases. This includes the process of obtaining a thorough history, performing a comprehensive clinical examination, performing vital signs, and ordering appropriate investigations that provide the clinician with key information vital to establishing a final diagnosis. The categories and classification systems of oral diseases as well as the indications for referrals and consultations with other health-care providers and guidelines for documentation are reviewed.

Introduction

Oral medicine is a specialty at the interface of medicine and dentistry, focused on the diagnosis and nonsurgical management of medically related disorders of the oral and maxillofacial region (Scully et al. 2016; Stoopler et al. 2011). The scope of practice of an oral medicine specialist involves the evaluation of patients with a wide range of maxillofacial conditions including “oral mucosal disorders, orofacial pain, temporomandibular disorders, salivary gland disorders, chemosensory disorders, sleep disorders, oral manifestations of systemic disorders, as well as the dental treatment of medically compromised patients” (Sollecito et al. 2013). The oral cavity is the gateway to the body; therefore, oral health is an essential component of overall systemic health. Many systemic disorders have oral manifestations; conversely, the oral management of patients may be impacted by the presence of systemic disorders (Stoopler and Sollecito 2016). Therefore, it is important that oral healthcare providers are trained, not only to diagnose and manage patients with odontogenic diseases (i.e., dental caries/odontogenic infections, periodontal diseases, and malpositioned teeth/jaws) but also to effectively diagnose other oral diseases within the scope of oral medicine and provide safe dental treatment to those patients with underlying systemic disorders (Miller et al. 2001). This chapter addresses the necessary steps involved in the evaluation of patients who present with such diseases, both soft and hard tissue diseases. This includes the process of obtaining a thorough history, performing a comprehensive clinical examination, performing vital signs, and ordering appropriate investigations such as laboratory tests and imaging, that provide the clinician with key information vital to establishing a final diagnosis. The categories and classification systems of oral diseases, a general overview of the diagnostic process, the indications for referrals and consultations with other healthcare providers, as well as guidelines for documentation are reviewed.

The Medical Record

The patient’s medical information obtained from a clinical evaluation is considered confidential and must be carefully documented and stored for future reference, in a safe and protected manner. The medical record is collected either as a paper-based health record or as an electronic health record (EHR). Transmission of information between multiple providers caring for the same patient is often inefficient, prone to errors, and slow with the use of paper-based health records. As clinical management of patients often requires input from multiple health-care providers, there has been a move by many countries to implement the use of EHR as a means of improving safety, efficiency, and accessibility of records across multiple sites (Ludwick and Doucette 2009). Irrespective of the type of record used, it is the responsibility of the oral health-care provider to obtain and record all information relevant to the patient’s treatment including all aspects of the history, examination findings, vital signs, and investigational reports such as clinical photographs, radiographs/medical imaging studies, laboratory tests, and histopathological findings.

The Patient History

The history is the information relevant to the patient’s health obtained by careful interview of the patient or a reliable source. For new patients, the initial goal of the history is to help reach a final diagnosis and formulate a treatment plan. For an established patient, the goal is to elicit new information to facilitate ongoing care. The patient’s history alone often reveals key elements of the information needed to reach a definitive diagnosis, and the importance of a thorough and systematic approach to collect this information cannot be underestimated. The history also aids in the risk assessment of patients prior to the provision of oral care as medical conditions that may increase 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 recognized. The process of history-taking provides an opportunity for the clinician to develop a rapport with the patient, which is necessary for effective communication during the interview and subsequent encounters. It is important for the clinician to make the patient comfortable bearing in mind that patients come from diverse social and cultural backgrounds with differing attitudes and beliefs to health care. The clinician should therefore encourage the participation of the patient in decision-making and should listen to the patient’s perceptions and concerns regarding their clinical problems respectfully and without bias. It is also important that the clinician greets the patient in a culturally appropriate manner, ensures that the interview location is private, and pays attention to the patient during the interview. The use of open-ended questions is preferred to direct questioning and clarification of the patient’s understanding should be sought when appropriate. Language barriers can be a major issue, and interpreters should be on hand to facilitate communication. In addition, parents or legal guardians must accompany minors and those with disabilities that limit communication. An exhaustive systematic approach should be followed for every patient, whether new or established. This will maximize the opportunity to capture all relevant information and minimize the risk of missing vital data. The master clinician with years of experience can often quickly and efficiently navigate the history, whereas the novice may be less efficient and take longer. The road to mastery is built on a disciplined systematic approach where there is no room for shortcuts. Table 1 provides the elements for taking both a new and established patient history.

Table 1 Elements of the new patient encounter

Biographical data: The biographical data are important for identification and administrative purposes as well as to ensure that the patient’s contact information is accurate and available for use when needed. This includes the patient’s name, contact information, date of birth, gender, race/ethnicity, primary language, occupation, and primary care physician’s name and contact information (and other pertinent specialists).

Chief concern: The chief concern states why the patient is in your office. It is a brief description of the primary reason for the patient’s consultation and evaluation recorded in the patient’s own words. Examples of chief concerns include oral lesions, pain, altered sensations (e.g., numbness, taste alterations), dry mouth or excessive saliva, halitosis, slow healing of a surgical wound, facial or oral/neck swelling, abnormal bleeding, an alteration in oral function (e.g., chewing, swallowing), or tooth abnormalities.

History of presenting concern: The history of presenting concern is an exhaustive chronological account of all aspects of the chief concern obtained by carefully interviewing the patient. The following information should be documented as part of the history of presenting concern, and the reader is alerted to Table 2 where examples of specific questions for selected categories of chief complaints are provided.

• (i) Onset of symptoms: Determine when the symptoms started and if the onset was sudden or gradual.

• (ii) Anatomic site(s): Determine the anatomic site affected and ascertain whether the symptoms involve a single anatomic location or multiple sites.

• (iii) Description of symptoms: This includes a description of the course of symptoms and their characteristics considering both qualitative and quantitative descriptors. Establish whether the symptoms are occurring for the first time or recurring. Determine whether the symptoms are constant or episodic. Also, find out whether symptoms are stable, worsening, or improving. Ask the patient to describe the characteristics of the symptoms, in their own words, using qualitative descriptors such as dull, sharp, throbbing, aching, stabbing, electric shock-like, burning, dry, itchy, thick, rough, bumpy, swollen. Pain or discomfort should be rated quantitatively using a scale such as visual analog/numerical rating scale from 1 (minimal) to 10 (unbearable) or a Wong-Baker Faces scale (Fig. 1) (Wong-Baker FACES Foundation 2016). Enquire about the impact of the symptoms on the patient’s quality of life.

• (iv) Precipitating factors: Enquire about any factors that triggered the onset or that exacerbated the symptoms.

• (v) Aggravating/relieving factors: Determine what makes the symptoms better or worse.

• (vi) Secondary signs or symptoms: These are separate from the primary symptom(s) and often the patient may be unaware they may be correlated with the underlying problem (e.g., primary herpetic gingivostomatitis can be associated with fever and malaise, or sleep issues may lead to an increase in orofacial pain).

• (vii) History of past investigations and treatments: Prior diagnoses, investigations, and treatment modalities for the chief concern should be noted including pertinent negative results and failed treatments such as medication regimens.

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 2 History of presenting concern

Medical history: Although a self-administered health history form is routinely utilized for obtaining medical history information from patients, it is not equivalent to an exhaustive history. It is imperative that the oral healthcare provider verbally reviews all entries on the health-history form with all patients and supplements the history with additional questions as deemed necessary.

• (i) Current medical diagnoses: A thorough medical history should be elicited to include details of the patient’s current medical diagnosis as well as treatment modalities. The oral health-care provider should determine if the patient has been diagnosed with any of the medical conditions listed in Table 3. Information relevant to the onset of diagnosis, course of disease, associated complications, and level of control should be documented. This will facilitate risk assessment and the identification of conditions that may necessitate modifications to treatment. In addition, it is important to include information on routine health maintenance, the type of medical specialist managing the patient, as well as the frequency of office visits. For example, the medical history on a 57-year-old diabetic female patient would include information on date of diagnosis, frequency of office visits to her endocrinologist and/or primary care physician, home blood glucose test results, HbA1c, and target organ damage. The medical history should also include all relevant details of treatment modalities, which can potentially alter the delivery of care, such as implanted defibrillators in patients with cardiovascular disorders, chemotherapy scheduling in oncology patients, dialysis scheduling in patients with end-stage renal disease, and a chronicle of total joint replacements.

  Table 3 Pertinent medical history

• (ii) Past medical history: Patients should be asked if they have had any relevant medical problems in the past. The history should include previous major illnesses, consultations and referrals to specialists and their outcomes, hospitalizations, surgeries, major trauma, and blood transfusions.

• (iii) Current medications: Document all current medications and supplements taken by the patient. These include prescription medications, over-the-counter medications, vitamins, herbal supplements, and traditional home remedies. The name, dosage, route, frequency, start date, and reason why the patient is taking each medication should be noted. Online medication references have evolved rapidly and are indispensable tools that should be utilized for checking the category, mechanism of action, dosing and administration details, adverse reactions, and interactions. When possible, the generic medication name should be used for the purposes of recording the medications in the patient’s record. When patients are unsure of the medications they are taking, it is important to seek clarification from their physician or pharmacist. Clinicians should be alerted to specific medications that have increased potential for adverse events and that can influence treatment decisions, such as antiresorptive agents (e.g., bisphosphonates), anticoagulants, immunosuppressants (e.g., corticosteroids), immunomodulators, and medications for treating cancer (e.g., chemotherapy and immune therapies).

• (iv) Allergies: History of drug, food, and environmental allergies should be carefully documented. The type of allergic reaction experienced as well as the severity of the episode should be noted (e.g., contact dermatitis, anaphylactic reaction). It is important to make a distinction between adverse reactions to medications and true allergy. For example, gastrointestinal side effects such as nausea, vomiting, and constipation may not be related to an allergic reaction.

• (v) Review of systems: The review of systems is a careful and systematic review of relevant signs and symptoms related to different body systems that the patient may be experiencing or has experienced in the recent past (see Table 4). As an integral part of the medical history, the review of systems is helpful in identifying other medical problems that have not yet been diagnosed (e.g., polydipsia, polyphagia, polyuria in a patient who has not been diagnosed with diabetes mellitus). Review of systems is also helpful in assessing the severity of diagnosed medical problems. An example would be dyspnea with mild activity versus strenuous exercise in a patient diagnosed with congestive heart failure. Finally, the review of systems can uncover pertinent details relevant to the chief concern/history of presenting concern, which will aid in reaching a diagnosis (e.g., skin and genital lesions in a patient with oral ulcers secondary to Behcet’s disease). Both positive and negative responses should be documented. All positive responses should be followed up with more in-depth and focused questions and these patients should be referred to their physicians for further evaluation and management as indicated.

  Table 4 Review of systems

• (vi) Family medical history: This should include information on hereditary diseases (e.g., hemophilia), familial illnesses (e.g., recurrent aphthous stomatitis, hypertension, diabetes mellitus, cancers, psychiatric disorders, alcohol, and drug addiction), contagious infections (e.g., tuberculosis), and illnesses arising from environmental exposure to toxins. The relationship of the patient to the affected relative, current status of the relative (alive or deceased), and cause of death if deceased should be noted.

• (vii) Sexual history: Information related to the patient’s sexual history (sexual relationships, practices, and number of partners) relevant to their chief concern or examination findings should be documented. This is particularly relevant to infectious diseases with the potential to have oral manifestations including human immunodeficiency virus (HIV) infection, syphilis, gonorrhea, human papilloma virus (HPV) infections, herpes simplex virus (HSV) infection, infectious mononucleosis, and hepatitis B or C.

• (viii) Psychological history: The psychological history is an important element of the medical history that may be overlooked. Patients suffering from depression, anxiety, or other mental illnesses require careful evaluation, and a comprehensive history of their clinical course and treatments, including medications, must be elicited. Patients who appear to have undiagnosed mental illness should be referred to a primary care provider.

Social history: The patient’s social history will reveal information about the following domains:

• (i) Relationship status: This will provide insight on the level of support available to the patient. Find out whether the patient is single, married, divorced, in a domestic partnership, or in a long-term relationship.

• (ii) Children: Find out if the patient has children and their level of dependency. Alternatively, if they are older, can they provide additional support as needed by the patient?

• (iii) Occupation: It is helpful to know the type of work the patient does (e.g., outdoors vs. indoors).

• (iv) Cultural and religious beliefs: With the growing trend in immigration and population migration, oral health-care providers should be cognizant of the fact that patients come from different backgrounds with various cultural and religious beliefs, which can impact provision of care. Patients from certain ethnicities may decline oral medications and opt for herbal and traditional remedies while others may be unable to comply with instructions during periods of fasting. Based on their religious doctrine that blood is sacred, Jehovah’s Witnesses do not accept transfusion of whole blood and its four major derivatives (red cells, white cells, plasma, and platelets) but may accept transfusion of blood products such as clotting factors, erythropoietin, and immunoglobulins (Sarteschi 2004).

• (v) Tobacco use: Tobacco use is a leading cause of preventable death. According to the World Health Organization (WHO), there are one billion smokers worldwide and tobacco use is a public health threat leading to the death of approximately six million people a year (WHO 2016). Tobacco products adversely affect nearly every human organ system. Exposure leads to the development of a wide range of disorders including systemic diseases (e.g., cardiovascular diseases, respiratory diseases, and cancers) and oral diseases (e.g., periodontal disease, oral potentially malignant disorders, and oral cancer) resulting in reduced quality of life and life expectancy. Oral health-care providers can make a significant impact by asking every patient about tobacco use and providing applicable tobacco cessation educational resources. They should be aware of the different types of tobacco products available, such as smoked tobacco products (cigarettes, cigars, and pipe), clove cigarettes known as kreteks, bidis (coarse tobacco rolled in a tree leaf from South Asia), hookah (the smoking of flavored tobacco with a form of water-pipe (Waziry et al. 2016)), and smokeless tobacco formulations including snuff, snus (Swedish-style tobacco), and paan/betel quid (areca nut and tobacco wrapped in a betel leaf and chewed), and gutkha (an areca nut tobacco mixture sold in single use sachets and chewed) (Couch et al. 2016). E-cigarettes are relatively new handheld nicotine delivery systems that produce a vaporized flavored liquid by pressing a button. The long-term oral and systemic health risks of e-cigarettes are currently unknown (Couch et al. 2016). The risk of oral and pharyngeal cancers increases the longer a person smokes. The use of paan, betel quid and related products, which are usually placed in the oral vestibules, increases the risk of submucous fibrosis, a precancerous condition characterized by oral burning and limited mouth opening (Tilakaratne et al. 2016). The tobacco history, therefore, should include information on current and past use, the type of tobacco products, duration and frequency of use, and details about cessation attempts, if any. A cumulative cigarette smoking history should be documented in pack-years (number of 20 cigarette-packs per day multiplied by the number of years smoked).

• (vi) Alcohol use: Alcohol use disorder is common in society and alcohol use can lead to multiorgan consequences, some of which carry significant morbidity and mortality (e.g., liver cirrhosis). Studies have shown an association between the consumption of alcohol and the risk of oral cancer (Ogden 2005). Alcohol potentiates the carcinogenic effect of tobacco in a synergistic manner, thereby multiplying the risk of oral cancer (Petersen 2009; Reidy et al. 2011). Oral health-care providers can and should elicit a history of alcohol use, and collect information about current or past use, types of alcoholic beverages consumed, current drinking patterns (i.e., how many days a month or week, the time of day when the patient consumes alcohol), and quantity (number of units of alcohol/week). It is important to appreciate the dose equivalents for alcoholic beverages [i.e., a 12 oz. beer (5% alcohol) is equivalent to a 5 oz. glass of table wine (12% alcohol) or a 1.5 oz. distilled alcoholic drink (40% alcohol)]. Low risk use is defined as either fewer than three units of alcohol at a sitting or seven or less units of alcohol/week for women, and either fewer than four units at a sitting or 14 or less units of alcohol/week for men. Higher rates carry significantly higher risk for alcohol use disorder (NIAAA (National Institute on Alcohol Abuse and Alcoholism) 2005). It is also important to assess the impact of alcohol, if any, on the patient’s quality of life by finding out if alcohol has adversely affected their mood, behavior, diet, occupation, and relationships in which case referral to a medical professional may be indicated. This can be done using the Diagnostic and Statistical Manual of Mental Disorders available from the National Institute on Alcohol Abuse and Alcoholism (Table 5) (NIAAA 2016), (DSM–5) diagnostic criteria for abuse and dependence.

  Table 5 Assessment for alcohol use disorder

• (vii) Illicit drug use: This encompasses the nonmedical use of prescription drugs (e.g., opioids, barbiturates, and amphetamines) and illicit drugs (such as cocaine and heroin) (Degenhardt and Hall 2012). Marijuana is considered an illicit drug in most countries. Enquire about current and past history of drug use, the type(s) used, the route of administration (i.e., intravenous, inhaled, smoked, or consumed by mouth), and any treatment for addiction. It is important to consider prescribing medications without increased potential for addiction to patients with a history of drug abuse and dependence. Also, current use of some illicit drugs may potentially interact with local anesthesia or medications prescribed by oral physicians (e.g., cocaine).

• (viii) Recent travel history: This has become more important with respect to recent travel to geographic regions with endemic diseases such as tuberculosis, Ebola, leishmaniasis, or Zika virus.

Dental history: The dental history can provide additional information related to the chief concern that is valuable in reaching a diagnosis. It is also important for evaluating the patient’s level of dental awareness, motivation, utilization of dental services, and risk/susceptibility for dental disease. The following should be documented as part of the dental history:

• (i) Current dental symptoms: Pain, swelling, halitosis, bleeding, mobile, or fractured teeth.

• (ii) Last dental visit and reason for seeking dental care: Emergency or routine dental care.

• (iii) Frequency of dental visits.

• (iv) Previous dental treatments: Recall visits/dental prophylaxis, restorative dentistry, oral surgery, implants, orthodontics, periodontics, endodontics, and fixed and removable prosthodontics.

• (v) History of maxillofacial trauma.

• (vi) Home care: Brushing and flossing/interproximal habits (i.e., frequency, timing in the context of meals, and technique). Oral hygiene products such as dentifrices, flosses, and mouth rinses should be recorded as they can sometimes cause mucosal reactions.

• (vii) Oral habits: Clenching, bruxism, cheek biting, nail biting.

• (viii) History of temporomandibular joint (TMJ) pain, clicking or locking, and the use of orthotic devices or night guards.

• (ix) Exposure to fluoride and type of fluoride.

• (x) Presence of dental phobia and anxiety.

Nutritional history: Nutritional factors are associated with the development and progression of various oral and systemic diseases. Therefore, it is necessary to evaluate the nutritional and dietary habits of patients in relation to their chief concern and presenting symptoms. Oral health-care providers may also play a role in the interception and management of obesity and eating disorders (e.g., bulimia and anorexia nervosa). The following points may be considered when taking the nutritional history:

• (i) Dental caries: There are multiple risk factors for dental caries, a number of which are modifiable, including diet. Therefore, the nutritional history should include information on frequency of meals and snacks, and a detailed history of the consumption of sugared beverages (Marshall 2009).

• (ii) Periodontal diseases: Severe vitamin C deficiency (i.e., scurvy) is associated with periodontal disease.

• (iii) Dental erosion: Repeated exposure to acidic beverages (e.g., carbonated soda and sports drinks) can promote the initiation and progression of dental erosion. Patients who suffer from eating disorders such as anorexia nervosa and bulimia may practice self-induced vomiting leading to dental erosion on the lingual and palatal surfaces of teeth.

• (iv) Oral cancer: A diet rich in fruits and vegetables is protective against oral cancer.

• (v) Oral mucosal disorders and neuropathies: Vitamin B₁₂ deficiency may occur in strict vegetarians and is associated with glossitis and stomatitis. Chronic undernutrition and other vitamin deficiencies (B₂, B₆, folic acid) may predispose patients to angular cheilitis, stomatitis, oral ulcerations, and burning mouth symptoms.

• (vi) Major salivary gland enlargement: May be seen in patients with chronic malnutrition.

The Patient Examination

The history is followed by a comprehensive visual/tactile head and neck examination. Medical providers (i.e., primary care physicians) rarely perform a detailed intraoral examination, which underscores the important role of oral health-care providers in this regard. Yet, the patient examination performed by oral health-care providers goes far beyond the evaluation of dental and periodontal structures. Clinicians should have detailed knowledge of how to evaluate both oral and nonoral structures of the head and neck and perform a cranial nerve examination. An understanding of normal anatomy and function facilitates the detection of abnormalities during the examination. The interplay between the history and the examination deepens as the clinician explores new avenues of questioning based upon the detection of such abnormalities. This section emphasizes the importance of performing a consistent and comprehensive examination, a skill that is vastly undervalued and yet, when performed correctly, can yield important clues to the diagnostic process. With practice, this examination should not take longer than a few minutes on average. Table 1 summarizes the steps.

Extraoral examination: This part of the examination has been broken into eight sections and requires the patient to loosen/remove any clothing to allow visualization of the head and neck structures:

• (i) General inspection: During the history taking an astute clinician has already begun the examination process by performing a visual inspection of the patient. Height and weight; dress and personal hygiene; posture and gait; dexterity and body movements; eye movements and facial expression; speech, mood, and cognitive ability; and others may be gauged over the first few minutes of the patient encounter. Height and weight may be combined to assess a patient’s body mass index (BMI), calculated as the weight in kilograms (kg) divided by the height in meters squared (m²).

• (ii) Skin/hair: Clinicians should evaluate the head, face, and neck, or any other visible areas of skin (i.e., hands, arms, legs, or feet) noting the texture, turgor, color, and obvious asymmetry, growths, or lesions (e.g., pigmented or ulcerated skin lesions). Fingernails and hair distribution should also be evaluated (e.g., hair loss or fingernail pathology such as onychomycosis).

• (iii) Eyes: Observe general features such as eye position, eyelids, lashes, and structures of the eyeball (cornea, sclera, iris, pupils, tear production, noting any asymmetry). Assessment of visual acuity and ocular function is covered in the cranial nerve assessment.

• (iv) Temporomandibular joints (TMJs): The TMJs may be examined by placing the index fingers anterior to the tragus of the ears and asking the patient to open and close their jaws (Fig. 2a). This will allow the clinician to locate the lateral poles of the condyles, palpate any TMJ swelling or pain, assess the rotation and translation of the condyles, and detect joint sounds (i.e., crepitus, clicks, or pops), or deviations/limitations in the normal range of jaw movement. Subtle joint sounds may be appreciated more easily by using a stethoscope. The range of motion is an easily reproducible measure of jaw movement. The normal range for maximum opening is variable (approximately 40–60 mm) and obtained by precisely measuring the interincisal distance with a ruler (Fig. 2b) or vernier calipers, or crudely by the number of fingers one is able to insert between the teeth. Three fingers (measuring approximately 47 mm) is a reliable surrogate for normal opening (Zawawi et al. 2003). Observing excursive jaw movements (i.e., protrusion, or lateral excursions of approximately 7 mm) reveal limitations in range, allow comparison between sides (i.e., asymmetry), and show which movements, if any cause pain or other signs.

• (v) Muscles of mastication and other head and neck musculature: There are four main pairs of masticatory muscles: masseters, temporalis, medial pterygoids, and lateral pterygoids. All are innervated by the mandibular branch of the trigeminal nerve (V3), and therefore V3 nerve function may be assessed when examining these muscles. The examination of the muscles of mastication begins with a visual inspection for any asymmetry or gross enlargement of the masseters and temporalis muscles at rest. Then the patient is asked to clench their teeth in order to visualize and palpate muscle contraction and assess strength, symmetry, and size of the muscles. At a minimum, digital palpation of the masseters and temporalis muscles should be performed (the predictive value of palpating the pterygoids is low) and may reveal muscle tenderness or pain, or indicate sites of referred pain. It is important to assess each muscle in turn using consistent pressure (approximately 1 kg), palpating at multiple points, for approximately 2 s each, along the length of the muscles, comparing right to left. Identified painful trigger points may be palpated for up to 5 s to appreciate referral patterns (Schiffman et al. 2014). The use of an algometer may assist in providing consistent pressure. The anterior (Fig. 3a) and more posteriorly the middle and posterior aspects of the temporalis muscles may be examined in turn, followed by the masseter muscles (Fig. 3b). The tendon of the temporalis at the coronoid process of the mandible may be palpated intraorally. Ask patients to provide a rating of any tenderness or pain (0 for no tenderness, 1 for uncomfortable tenderness, 2 for definite tenderness or pain, or 3 for significant pain that causes the patient to pull away to avoid further pain). The lateral and medial pterygoids are difficult to reliably palpate but may be assessed functionally. Pain elicited when protruding the jaw with resistance from the examiner may indicate the inferior lateral pterygoid muscles as a possible source. The power stroke of biting down on an object may result in pain from the superior lateral pterygoid muscles. Neck muscles, such as the sternocleidomastoids, posterior cervical muscles (i.e., trapezius, longissimus (capitis and cervicis), splenius (capitis and cervicis), and levator scapulae), and strap muscles of the neck may be similarly palpated and also evaluated for range of motion by turning the head all the way to the left, then to the right, then lifting the chin up, and then tilting the head left and right.

• (vi) Salivary glands: There are three paired major salivary glands (parotid, submandibular, and sublingual glands) along with greater than 300 minor salivary glands distributed throughout the mouth. Assessment begins with a visual inspection of the parotid and submandibular glands for swelling or asymmetry. There are a number of chronic disease processes (e.g., diabetes or liver disease) that can manifest with bilateral salivary gland enlargement. In health, palpation of the salivary glands will reveal a soft consistency without tenderness.

• (vii) Midline neck structures (trachea and thyroid gland): Examination of the trachea is warranted to rule out displacement or change in axial mobility, possibly due to the encroachment of neck neoplasms. The trachea extends inferiorly from the larynx, and half of the trachea is within the neck. Tracheal displacement from its midline position may be verified by both inspection and palpation of the trachea in relation to the suprasternal notch. By gently grasping the tracheal rings, the trachea can be moved laterally and a grating is appreciated because of the movement of the cartilaginous rings. Equal movement and grating is a normal finding. The thyroid is a bilobed gland found in the midline of the lower neck. The lobes are joined by an isthmus, which crosses in front of the trachea inferior to the level of the cricoid cartilage. The lobes extend laterally with the most lateral aspects of the gland found deep to the sternocleidomastoid muscles (Fig. 4a). The first step to examining the thyroid is the inspection (both from in front and from the side of the patient) for any obvious asymmetry or swelling (e.g., a goiter or thyroid neoplasm). Since the thyroid gland moves with the trachea during swallowing, the patient can be asked to swallow a sip of water, facilitating visualization as the thyroid tissue moves superiorly. This is followed by palpation, performed either from behind (i.e., the posterior approach) or in front of the patient to detect any discrete nodules within the gland or its associated lymph nodes. The prominence of the thyroid cartilage (Adam’s apple) is an easy first landmark to detect manually. The next ring inferior is the cricoid cartilage, and just inferior to this is the location of the isthmus. Pushing the sternocleidomastoid muscles laterally and posteriorly, it is possible to palpate the lobes in turn by applying light pressure, comparing the right and left sides for asymmetry (Fig. 4b).

• (viii) Lymph nodes: An understanding of the lymphatic drainage of the head and neck is a prerequisite for this step of the extraoral examination. There is a collar of lymph nodes of the head that drain into the deeper neck lymph nodes, which ultimately drain into the thorax (Fig. 5a, b). The head and neck lymph node system is divided into levels (I–VI) from superior to inferior. Superficially located lymph nodes are palpable in health, and they are soft, moveable, and nontender. Deeper nodes may become palpable when enlarged (lymphadenopathy). Most commonly, lymphadenopathy is due to an inflammatory etiology (e.g., an odontogenic infection) and involved lymph nodes become enlarged and tender, although they typically remain soft and moveable. Lymphadenopathy can occur in association with cancer metastasis (e.g., squamous cell carcinoma) and are typically enlarged, firm to palpation, nontender and, if there is extracapsular spread, they may become nonmovable or fixed. Level I nodes are detected in the submandibular and submental triangles of the neck. Level II, III, and IV lymph nodes may be detected within the anterior triangle of the neck, and level V nodes in the posterior triangle of the neck. Level VI nodes are found below the hyoid bone in the anterior central aspect of the neck. Following the examination of the thyroid gland, it makes sense to begin the lymph node examination in the anterior triangle, then move into the posterior triangle, and end with the submandibular and submental triangles. The boundaries of the anterior triangle of the neck are the midline of the neck anteriorly, the sternocleidomastoid muscle posteriorly, and the inferior border of the mandible superiorly (Fig. 6a). The level II, III, and IV deep lateral cervical nodes follow the path of the internal jugular vein deep to the sternocleidomastoid muscle. Look for the outline of the sternocleidomastoid muscles, and asking the patient to lift and turn their head away from the side being examined is often helpful to identify this muscle. With the neck relaxed, it is possible to palpate anterior and deep to the muscle from superior to inferior, and compare findings from both sides (Fig. 6b). The boundaries of the posterior triangle are the sternocleidomastoid muscle anteriorly, the trapezius muscle posteriorly, and the clavicle inferiorly (Fig. 7a). Palpate along the posterior border of the sternocleidomastoid muscle from the supraclavicular nodes inferiorly to the postauricular and occipital nodes superiorly (Fig. 7b). The submandibular and submental triangles comprise the most superior aspect of the anterior triangle of the neck and contain level I nodes which receive drainage from most oral structures (Fig. 8a). Submandibular nodes are generally superficial and therefore palpable in health, allowing the examiner to feel the characteristics of healthy nodes. Have the patient lower their chin and then gently pull the soft tissues laterally across the inferior border of the mandible (Fig. 8b). In this way, it is possible to “capture” the node between the examiner’s finger and the inferior border, and then feel the node “pop” back into place. Similarly, submental nodes may be palpated by moving the submental soft tissues anteriorly (Fig. 8c). Lymph nodes draining facial structures, such as the preauricular and buccal nodes may also be palpated.

  Fig. 2

  

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

  Fig. 3

  

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

  Fig. 4

  

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

  Fig. 5

  

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

  Fig. 6

  

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

  Fig. 7

  

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

  Fig. 8

  

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

Intraoral examination: This part of the examination is rarely performed in a comprehensive manner by health-care providers outside of dentistry, and as such, it is critical to perform it when the opportunity arises, certainly for all new patients, for all recall visits, and during emergency/urgent care visits regardless of the type of emergency/urgency. Patients should be informed that they are receiving an oral examination to detect not only dental and periodontal problems but also to detect mucosal and other abnormalities, such as the rare instance of oral cancer. The concept of self-examination may also be broached with the patient, along with instructions of the steps they can perform at home. This exam is both visual and tactile (i.e., with palpation), and patients should be asked to remove removable dental appliances and to rinse out food particles. Develop a consistent examination sequence, the order of which is not that important, as long as all elements are completed. An adequate light source is critical to the intraoral examination. A standard overhead halogen dental light or, preferably, a portable light-emitting diode (LED) white headlight affixed to loupes should be used in order to keep both hands free. Other adjuncts include an air syringe, mouth mirrors, and gauze.

• (i) Lips: The lips’ vermillion border with the skin is normally sharply demarcated and homogenous in color and texture. Inspect and bimanually palpate the lip for surface changes or color irregularities (Fig. 9a).

• (ii) Labial mucosae: Reflect the lips to visualize the labial vestibule, and inspect/palpate for any surface or submucosal abnormalities (Fig. 9b–d).

• (iii) Gingivae: Inspect and palpate all gingival structures. Healthy gingivae should be pink, stippled, nonedematous, and have knife-edged interdental papillae (Fig. 9e).

• (iv) Buccal mucosae: Retract this tissue digitally or with a mouth mirror to inspect/palpate all aspects of the buccal mucosae, including the posterior aspects of the buccal vestibules. Palpate the parotid extraorally to evaluate salivary flow through the Stenson’s duct orifice (Fig. 9f).

• (v) Tongue: The tongue is divided into the “oral tongue” (the anterior two-third) and the base of tongue (the posterior one-third). The oral tongue is comprised of the dorsal, lateral, and ventral surfaces, which are amenable to inspection and palpation. A piece of gauze may be wrapped around the tongue to allow access to the posterior aspects of the dorsum and posterolateral border of the tongue where the foliate papillae and lymphoid tissues may be inspected/palpated and compared bilaterally (Fig. 9g–i). The dorsal tongue harbors a number of specialized papillae, namely a row of round, pink, mildly elevated circumvallate papillae dotted in a V-distribution at the posterior border of the oral tongue; small red fungiform papillae distributed throughout the dorsal surface (and often concentrated at the tip of the tongue); and most commonly the tiny fingerlike keratinized filiform papillae. The foliate, circumvallate, and fungiform papillae house taste buds. The ventral tongue has a thin mucosal lining contiguous with the floor of mouth, contains a midline frenum, plica frimbriata lateral to the frenum, and one may observe the deep lingual veins (Fig. 9j). The posterior one-third of the tongue is more difficult to visualize directly; however, it should be palpated and/or visualized indirectly by mirror or endoscopy, gag reflex permitting (Fig. 9n, o).

• (vi) Floor of mouth: Since abnormal surface changes may be subtle, air-drying this region facilitates examination. The sublingual caruncles or sublingual papillae are two small round structures found either side of the frenum, and these house Wharton’s duct openings. Fanning out laterally from these papillae are elevated sublingual folds containing the openings from the sublingual glands (Fig. 9k). Bimanual palpation of the floor of mouth should be performed by gently moving two opposing fingers, one extraorally and the other intraorally, from posterior to anterior, softly palpating the interposing soft tissue (Fig. 9p).

• (vii) Hard palate: Inspection and palpation of the hard palate is important. Small mucosal swellings are easy to miss when the examiner relies on inspection alone (Fig. 9l).

• (viii) Oropharynx: The oropharynx comprises the soft palate, the uvula, anterior and posterior pillars (or fauces), the posterior pharyngeal wall, the palatine tonsils, and base of tongue (Fig. 9m). These structures, along with the nasopharyngeal and lingual tonsils comprise Waldeyer’s ring, part of the mucosal immune system. A tongue blade or mouth mirror may be used to depress the tongue. This is the opportunity to assess cranial nerves IX and X by provoking a gag reflex and having the patient say “aahh” and watch the even elevation of the soft palate. The retromolar trigone is the area distal to the mandibular retromolar pad and this should be part of the examination. The palatine tonsils sit in the tonsillar fossae between the pillars. It is important to record their presence (many patients have had them surgically removed), color, and symmetry. The base of tongue contains the lingual tonsils.

• (ix) Dentition: A detailed description of the examination of the teeth and supporting structures to detect common dental diseases (i.e., caries and periodontal disease) is beyond the scope of this book. However, the state of the dentition can provide insights about the overall health of the patient, and a careful examination of the dentition to detect dental abnormalities beyond caries, periodontitis, odontogenic infections, and occlusal/jaw discrepancies (i.e., that might typically be managed orthodontically) is warranted. Examples are dental erosion, disorders of enamel or dentin formation, and intrinsic or extrinsic discoloration (e.g., secondary to tetracycline use). Deviations from the normal tooth number, shape, color, eruption patterns, and occlusion offer the initial clues. The involvement may be restricted to a single tooth, multiple teeth, or be generalized to the entire dentition. These clues provide the basis for further probing of the patient’s history, including family history (e.g., where a hereditary disease, such as amelogenesis imperfecta, might be suspected). The clinical examination may need to be supplemented with radiographs (or other diagnostic testing) to further characterize the abnormalities. Clinicians should also assess the relationship of teeth to the surrounding mucosae. Broken and sharp teeth, restorations, or dentures can lead to frictional keratosis or traumatic ulcers. Large amalgam restorations can cause local lichenoid reactions of the adjacent mucosa.

• (x) Saliva: Salivary gland function may be crudely assessed by identifying the gland openings intraorally ( Stenson’s ducts from the parotid glands open on the buccal mucosae near the maxillary second molar, and Wharton’s ducts emanate from the sublingual caruncles in the floor of mouth), and then “milking” each gland and observing saliva secretion. The presence, consistency/viscosity (normal viscosity versus thick/stringy, or bubbly), and color of the saliva (clear vs. turbid) may be recorded, although a reduction or absence of saliva may not necessarily be associated with true salivary gland hypofunction (e.g., dehydration). Other signs of normal salivary flow may include a glistening of mucosal surfaces commensurate with adequate saliva and the presence of salivary pooling in the floor of the mouth. Clinicians should also look for signs of salivary dysfunction (see chapter “Salivary Gland Disorders and Diseases”).

  The gold standard for the assessment of normal salivary gland function is by sialometry, measuring the quantity and quality of saliva generated by the glands in both the basal (unstimulated) state and during stimulation, either by measuring the collective secretions from all the glands (i.e., whole saliva) or by measuring saliva from each gland individually. Ideally, sialometry should be performed during a morning appointment with the patient instructed not to eat or drink (except water as needed) for 90 min before the appointment. With the patient in a relaxed state and in a quiet environment, the procedures of saliva collection should be clearly explained to the patient. Sitting in an upright position, the patient should be instructed to swallow their saliva, tilt their head forward, and place a preweighed collecting tube next to their mouth (Navazesh et al. 2008). Setting the timer for 5 min or more, they should allow saliva to drool out of their mouth into the tube. At the end of the time, they should expectorate all residual saliva into the tube. The tube should be weighed to calculate the weight of saliva and the value divided by the number of minutes collected to generate a flow rate. One gram is equivalent to 1 mL of saliva and mean normal unstimulated flow rates are 0.3–0.4 mL/min. Stimulated salivary flow rates are performed if a patient has an abnormally low unstimulated flow rate (i.e., <0.2 mL/min) and may be measured by a number of techniques including asking the patient to chew a flavorless gum base, paraffin wax, or a sugarless lemon drop for 5 min, expectorating every 30 s during collection. The mean normal stimulated flow rate is 1–2 mL/min. In patients suspected to have dental erosion, salivary pH and buffering capacity can also be undertaken using commercially available kits (e.g., GC Saliva Check, GC Corporation, Japan).

  Sialometry to measure individual gland secretions, to detect salivary pH, buffering capacity, and composition is also possible, although not routinely performed outside of a research setting.

• (xi) Screening adjunctive techniques: These are defined as techniques that are applied to patients during an examination to provide additional information about the patient or a specific abnormality detected (e.g., the use of light-based visualization techniques such as tissue autofluorescence devices to screen for malignant and potentially malignant disorders). This is covered in more detail in the chapter “Oral Mucosal Malignancies.”

Fig. 9

Soft tissue examination: (a) Lips, (b) lower labial mucosa/vestibule, (c) palpation of lower lip, (d) upper labial mucosa/vestibule, (e) gingivae, (f) buccal mucosa, (g) dorsal tongue, (h) lateral border of tongue, (i) posterolateral tongue showing foliate papillae/lymphoid tissue, (j) ventral surface of tongue, (k) floor of mouth, (l) palpation of hard palate, (m) oropharynx, (n) indirect inspection of base of tongue, (o) palpation of base of tongue, (p) bimanual palpation of the floor of mouth

Cranial nerve examination: There are 12 cranial nerves (CN), although routine assessment of every cranial nerve is not typically indicated. Oral health-care providers will routinely test cranial nerves V, VII, IX, X, and XII during a routine examination. The others may be tested when there is an indication.

• (i) Olfactory nerve (CN I): The sense of smell may be tested using familiar inoffensive odors, such as soap. First assess the patency of each nasal passage by asking the patient to occlude one side and then breathe through the open passage of the other side. If both are patent, ask the patient to close their eyes, occlude one nostril at a time and sniff the smell of the selected substance. Ask them to name the substance and test both sides.

• (ii) Optic nerve (CN II): Visual acuity may be tested using a Snellen chart. Patients are positioned 20 ft from the chart (alternatively, a miniature hand chart may be used) and asked to cover one eye and then read the smallest line of print possible. Visual acuity is expressed as two numbers (e.g., 20/40). The first is the distance from the patient to the chart, and the second is the distance at which the patient’s eye can read the line of the smallest numbers. Visual fields may also be assessed via confrontation testing, usually by the static finger wiggle test and the kinetic red target test. Pupillary reactions are mediated by CNs II and III (see below).

• (iii) Oculomotor nerve (CN III): The pupillary reflex (also mediated by CN II) may be assessed through two reactions: the light reaction and the near reaction. The light reaction is assessed by shining a light into one eye which should lead to pupillary constriction in both eyes (the light is sensed by the retina, which stimulates the optic nerve, and then impulses are sent from the brain back via CN III to cause the pupil to constrict (i.e., iris muscle dilation)). The near reaction is when the patient is asked to focus their gaze on an object, such as a finger placed equidistant from both eyes, that is brought closer and leads to pupillary constriction (i.e., accommodation). CN III also provides motor innervation to most of the extraocular muscles (i.e., all except the lateral rectus and superior oblique muscles), along with the levator palpebrae superioris muscles (to elevate the upper eyelid).

• (iv) Trochlear nerve (CN IV): This nerve provides motor innervation to the superior oblique muscle and is assessed along with CNs III and VI by instructing the patient to follow the six extraocular movements (i.e., an “H” shape made by a finger or pencil): all the way to one side, then up and down, then all the way to the other side, then up and down.

• (v) Trigeminal nerve (CN V): This nerve has three divisions, two of which are sensory ( V1: ophthalmic and V2: maxillary) and one which is both sensory and motor (V3: mandibular). The sensory nerves may be assessed by having the patient close their eyes and then lightly touching the facial skin distribution, on both sides, of the three sensory branches. Then, perform the same steps with a pin or sharp object. Ask the patient to tell you where they feel the sensation, and the type of sensation (soft touch or sharp prick), comparing sides. The corneal reflex (V1) may be assessed by touching the cornea with a wisp of cotton and observing a blink. Motor branches to the muscles of mastication may be assessed by asking the patient to clench their jaws and observing bilateral contraction of the masseters and temporalis muscles. The patient’s ability to perform symmetric jaw movements (opening, closing, lateral, and protrusive jaw movements) may be assessed too.

• (vi) Abducens nerve (CN VI): This nerve provides motor innervation to the lateral rectus ocular muscle, and assessment is similar to that of CNs II and IV.

• (vii) Facial nerve (CN VII): This nerve provides motor innervation to the muscles of facial expression and also carries taste and other sensory neurons. The motor portion may be assessed by asking patients to perform a number of facial grimaces, such as wrinkling their forehead (contracting the frontalis muscles), tightly contracting the eyelids (orbicularis oculi), or smiling and showing the teeth (orbicularis oris). Look for symmetry.

• (viii) Vestibulocochlear nerve (CN VIII): Auditory acuity may be simply assessed by the whispered voice test. Standing behind the patient so they cannot see the lips of the examiner, simultaneously occlude the nontest ear and gently rub the external meatus, then exhale completely and then whisper three random numbers from 6 in. away. Ask the patient to repeat the numbers and repeat on the other ear. For patients who fail this test, a tuning fork may be used to assess neurosensory and conductive hearing loss (i.e., the Rinne test for air and bone conduction, and the Weber test for lateralization). Assessment of the vestibular system is rarely performed as part of the routine cranial nerve examination.

• (ix) Glossopharyngeal nerve (CN IX): Visceral functions aside, this nerve provides motor innervation to the stylopharyngeus muscle which helps elevate the pharynx and larynx, and provides sensation to the posterior oral cavity including taste sensation from the posterior third of the tongue. It is usually assessed by testing the gag reflex, by placing a tongue depressor onto the posterior aspect of the tongue; however, absence of a gag reflex does not assure a glossopharyngeal nerve palsy.

• (x) Vagus nerve (CN X): The vagus provides motor innervation to other pharyngeal and laryngeal muscles, along with fibers to the heart, thoracic, and abdominal viscera. It may be assessed in conjunction with CN IX by asking the patient to say “ah” and watching the symmetric elevation of the soft palate and uvula.

• (xi) Spinal accessory nerve (CN XI): This is a motor nerve to the sternocleidomastoid (SCM) and trapezius muscles. The SCMs may be assessed asking the patient to turn their head against the force of your hand, and the trapezius muscles may be assessed by shrugging the shoulders against force. Look for symmetrical strength.

• (xii) Hypoglossal nerve (CN XII): This nerve provides motor innervation to the intrinsic and extrinsic tongue muscles. Look for symmetry at rest and then ask the patient to protrude their tongue. Fasciculation of the tongue or deviation may indicate an ipsilateral CN XII palsy.

Vital signs: Oral health-care providers should be able to perform vital signs on all patients; this includes blood pressure, heart rate and rhythm, respiration, temperature, and others.

• (i) Blood pressure: Blood pressure is typically measured chairside using a sphygmomanometer and stethoscope and is technique sensitive. Either arm may be selected (unless one arm has an A-V shunt for dialysis or has lymphedema secondary to a breast mastectomy), but the arm should be free of any clothing. The brachial artery should be palpated for a pulse (Fig. 10a) and the arm lifted so that the antecubital crease is at heart height, then the inflatable cuff is centered over the artery, positioned above the crease. Inflate the cuff until the radial pulse is eliminated and check the blood pressure reading. Deflate the cuff, place the bell-side of the stethoscope over the brachial artery, and reinflate to a pressure 30 mg Hg above the previous inflation value, and slowly deflate the cuff listening for two sets of sounds (Fig. 10b): the pressure at which the sounds are initially heard is the systolic pressure, and the pressure when the sounds are completely lost is the diastolic pressure. Blood pressure is calculated from the average of two readings (one on each arm). A threshold blood pressure reading of ≥90 mg Hg diastolic in an adult aged 30–59 years or readings of either ≥150 mg Hg systolic or ≥90 mg Hg diastolic in adults >60 years is indicative of hypertension and a strong recommendation for initiation of pharmacotherapy (Grade A evidence) (James et al. 2014). There are a number of scenarios leading to false positive (e.g., white coat hypertension, or recent coffee intake) or false negative (e.g., orthostatic hypotension) blood pressures in a clinical setting. Serial ambulatory or home blood pressure testing will provide more predictable readings. Blood pressure readings in excess of ≥180 mg Hg systolic or ≥110 mg Hg diastolic are suggestive of a hypertensive urgency, regardless of the presence of associated signs and symptoms such as headache, nosebleeds, severe anxiety, or shortness of breath. Such patients require a more detailed examination to rule out underlying systemic diseases (e.g., renal disease).

• (ii) Heart rate and rhythm: The radial artery is typically chosen to assess this, and the clinician should place the pads of both the middle and index fingers just proximal to the wrist with sufficient pressure to detect the pulse (Fig. 10c). Assess the rhythm first, and if regular, count the pulse for 30 s then multiply the value by 2. The normal range is 50–90 beats/min and if the rate is abnormally high (tachycardia) or low (bradycardia), measure again for a full 60 s. If the rhythm is irregular, attempt to detect a pattern. Irregular rhythm, tachycardia, or bradycardia typically will indicate further cardiac testing (e.g., electrocardiography) to identify the underlying etiology.

• (iii) Respiration: The rate, rhythm, and depth of breathing may be observed over a 60-s period. A regular rhythm of approximately 20 breaths is normal.

• (iv) Temperature: An average normal oral temperature is 37 °C (98.6 °F), yet it can fluctuate to as low as 35.8 °C (96.4 °F) in the early morning or to as high as 37.3 °C (99.1 °F) in the evening. The oral temperature is performed preferably by an electronic thermometer with the tip placed under the tongue and with the lips closed.

• (v) Other vital signs: Pain assessment is considered a vital sign in most medical settings. There are a number of validated pain assessment tools available (see the chapter “Clinical Evaluation of Orofacial Pain”). Pulse oximetry is also considered a vital sign. It is a surrogate measure for arterial blood oxygen saturation and normal values are >90%.

Fig. 10

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

Imaging

Imaging studies, discussed in greater detail in the chapter “Diagnostic Imaging Principles and Applications in Head and Neck Pathology,” are important diagnostic tools. In addition to radiographic and other imaging modalities (i.e., magnetic resonance imaging (MRI)), this section will include digital photography and videography. Because most radiographs utilized by oral health-care providers carry the risk of radiation exposure, they should be carefully selected (Farman 2005). The choice of an imaging modality should therefore be based upon its ability to contribute to diagnosis and management and not on its availability. In addition to dental disease, radiographs should be ordered to visualize the bone underlying soft tissue lesions, for intraosseous pathology, trauma and suspected fractures, salivary gland disorders, TMJ pain, and dysfunction and to rule out intracranial lesions in specific patients. It is important for radiographs to show the full extent of all lesions captured. Key findings that should be put into consideration when interpreting jaw lesions include: location, number of lesions, shape, border characteristics, dimension, internal structure, cortical expansion, and effect on adjacent structures/teeth. Imaging modalities utilized in the head and neck region include the following:

Photography and videography in oral medicine: The documentation of examination abnormalities, typically by digital photography, serves a number of important functions. Firstly, images serve as a baseline record of the initial presentation of an abnormality that may be used for diagnosis, to communicate with colleagues who are part of the patient’s care, as part of a scientific publication, or for the purpose of comparison over a number of follow-up visits (e.g., to gauge response to treatment). Secondly, images can be used for patient education and may be sent to patients for their own records. Thirdly, images serve as part of the patient’s record. They “speak a thousand words” and can be useful from a medicolegal standpoint. Videography may also be useful to convey abnormal examination findings, such as a cranial nerve palsy or recording a procedure. There is a dizzying array of digital camera systems available to clinicians that range in cost and image output. Smart phones have become popular in medical photography for their simplicity, good image resolution, and ease of sharing images. Sophisticated digital cameras with macrolenses and ring flash systems are expensive, although they produce images suitable for publication quality, with excellent resolution and the ability to capture focused images of intraoral abnormalities with variable depth of field. Before taking images, the patient should provide written consent that covers all issues related to patient privacy, although these requirements may vary depending on local regulations. Patient positioning and the use of oral retractors will greatly facilitate the capture of quality images. The storage of images is also an important issue. If an electronic health record is being used, images should be uploaded as part of the patient’s record. If this is not feasible, images should be labeled with the date, and patient’s name and chart number on an encrypted computer or other storage device.

Plain films: Traditional dental radiographs include bitewings, periapicals, occlusal, and panoramic radiographs. Bitewing radiographs are particularly useful for visualizing interproximal caries. Intraoral periapical radiographs are useful for imaging the dentition and supporting structures, while occlusal radiographs of the maxilla and mandible are utilized for visualizing the palate and floor of the mouth, respectively. Panoramic radiographs are useful for gross evaluation of intraosseous lesions of the maxilla and mandible and the TMJ. Other maxillofacial radiographs may also be prescribed depending on the specific needs of the patient such as the occipitomental (Waters) skull projection used for visualization of the maxillary sinuses.

Computed tomography (CT): CTs are associated with a higher radiation dose compared with plain films but provide better anatomic details of the hard tissues. With the utilization of contrast media, soft tissue structures can also be visualized. In the maxillofacial region, they are useful for evaluating the extent of maxillary and mandibular cysts and tumors, salivary gland pathology, fascial space infections of the head and neck, and cervical lymph node involvement in head and neck cancer patients. Cone beam CT (CBCT) provides reduced radiation exposure compared with CT and is the imaging modality of choice for visualizing hard tissue structures when a limited field of the head and neck is to be evaluated.

Magnetic resonance imaging (MRI): Although expensive, MRIs have no associated radiation exposure and are excellent for visualization of soft tissues. In the maxillofacial region, they are indicated for evaluation of the articular disc and other soft tissue components of the TMJ, neoplasms, and salivary glands and to rule out intracranial lesions in specific subsets of orofacial pain patients such as those presenting with cranial nerve abnormalities or trigeminal neuralgia.

Other imaging modalities utilized in the maxillofacial region include ultrasonography and sialography for evaluation of salivary glands as well as positron emission tomography (PET) utilized for detection and monitoring of malignancies.

Diagnosis

Abnormal findings: Abnormal clinical features (i.e., symptoms and signs) should be accurately described and recorded. This disciplined process of accurately describing clinical features will greatly facilitate the diagnostic process and allow effective communication of findings with colleagues. It is helpful to develop a vocabulary of descriptors for the myriad of signs and symptoms patients may present with. As an example, oral lesions may be described by symptoms such as the sensation of a surface change or a growth, pain, fever, malaise, burning, sensitivity to acidic or spicy foods or beverages, taste changes, numbness, oral dryness, inability to chew, tooth mobility, bleeding, and others. Signs such as color, shape, number, location/distribution, symmetry, surface topographical features, margin definition, size, and tactile consistency of oral soft tissue lesions as well as the presence or absence of regional lymph nodes should be recorded. Table 6 provides a list of physical descriptors commonly applied to oral mucosal lesions. Similarly, for bone diseases/jaw lesions, the following nonradiographic features should be described and noted: asymmetry/bony expansion, palpation of cortex (bony hard, soft, egg shell), presence of bruit, tooth mobility, and displacement. Radiographic features include size, number, both single versus multifocal and localized versus generalized; position in the jaws; characteristics of lesion border/periphery such as well-defined versus poorly defined, punched-out, corticated, sclerotic; shape (e.g., circular, scalloped); internal structures such as radiolucent, radio-opaque, mixed radiolucent/radio-opaque, multilocular with or without septae; and changes in trabecular patterns or the presence of dystrophic calcifications and tooth-like structures.

Table 6 Descriptive terminology for oral lesions

Categories/classification systems of oral diseases: Oral and maxillofacial diseases encompass a wide variety of disorders with different etiologies and pathogenesis. It is always a challenge to adequately fit diseases into classification systems, and overlap is inevitable. Oral and maxillofacial diseases are initially grouped by their primary clinical features, such as soft tissue versus hard tissue/bone diseases, orofacial pain, temporomandibular disorders, salivary gland dysfunction (hypofunction vs. sialorrhea), neurosensory disorders (halitosis, taste changes, dysesthesias), movement disorders, dental anomalies, and subsequently each group branches into classification trees based on a myriad of different features.

As an example, the group of soft tissue diseases may be classified based on underlying disease process (Table 7), clinical appearance (Table 8), location (Table 9), or clinical behavior (Table 10). These classification systems can facilitate the process of narrowing down a list of possible diseases while formulating a differential diagnosis. Hard tissue diseases/jaw lesions are typically classified by their radiographic features, such as radiolucent (Table 11) versus radio-opaque or mixed lesions (Table 12).

Table 7 Differential diagnosis of oral mucosal diseases based on etiology

Table 8 Differential diagnosis of oral mucosal diseases based on clinical appearance

Table 9 Differential diagnosis of oral mucosal diseases based on location

Table 10 Differential diagnosis of ulcerative mucosal diseases based on clinical behavior

Table 11 Differential diagnosis of radiolucent jaw lesions

Table 12 Differential diagnosis of radiopaque and mixed jaw lesions

Differential diagnosis: Effective management of patients with oral and maxillofacial diseases hinges on the ability of the oral health-care provider to arrive at an accurate diagnosis. For some diseases, a clinical diagnosis that can be made based on the pathognomonic appearance of a lesion (e.g., fluid-filled vesicles of recurrent herpes labialis) is equivalent to the definitive diagnosis. However, other diagnoses are more elusive, and the clinician may not be able to single out a diagnosis, but is able to generate a “shortlist” of possible diagnoses, known as the differential diagnosis. This list of possible diagnoses is based on the patient’s history and physical examination findings and is ranked in order from most likely to least likely. The diagnosis placed at the top of a differential list is known as the working diagnosis. For novices, the initial differential diagnosis may be fairly broad in scope incorporating many different entities. In contrast, the experienced master clinician may have only two or three entities listed. Thorough knowledge of human anatomy, pathophysiology, and clinical behavior of oral and maxillofacial diseases is critical to ascertaining the correct diagnosis while avoiding dangerous medical errors. Figures 11–15 outline differential diagnosis algorithms for ulcerative, pigmented, white, red, and exophytic soft tissue lesions.

Fig. 11

Algorithm for ulcerative lesions

Fig. 12

Algorithm for pigmented lesions

Fig. 13

Algorithm for white lesions or lesions with a predominant white component

Fig. 14

Algorithm for red lesions or lesions with a predominant red component

Fig. 15

Algorithm for exophytic soft tissue lesions

Definitive diagnosis: The definitive diagnosis is based on the result of a gold standard test for diagnosing a particular disease such as histopathology to diagnose a squamous cell carcinoma. In many situations, arriving at an accurate definitive diagnosis from the differential diagnosis will necessitate an analytic process involving gathering additional clinical information from tests and investigations. The choice of diagnostic tests is based on the items in the differential diagnosis and the most appropriate tests should be chosen based on test accuracy. Types of investigations necessary to determine a diagnosis may be in the form of imaging studies, chairside diagnostic adjuncts, laboratory studies, and biopsy/histopathological studies. Data from the investigations are then correlated with the clinical findings before the final diagnosis is rendered. The management of the patient is based on the definitive diagnosis; therefore, it is imperative that the correct diagnosis is made.

• (i) Diagnostic adjuncts: Diagnostic adjuncts are applied to an identified lesion or lesions to provide additional information about the nature of the lesion. A number of diagnostic adjuncts may have utility in the characterization of potentially malignant disorders (e.g., light-based adjuncts, vital staining with toluidine blue, cytopathogical platforms, and salivary techniques) and a more detailed description about these adjuncts, their indications, and accuracy will be covered in the chapter “Oral Mucosal Malignancies.” The process of procuring cells from a lesion, typically from the lesion surface, is known as exfoliative cytology. Conditions amenable to exfoliative cytology are candidosis and possibly herpes simplex infections. Identified lesions may be sampled by scraping the surface with a metal spatula or cotton swab (i.e., a mucosal smear), plated on a glass slide, immediately fixed, and sent to a pathology laboratory for staining and microscopic analysis. Lesions that are suspected to be caused by or associated with candidiasis, yet not overtly obvious based on clinical features alone (e.g., erythematous candidosis), are indicated for a mucosal smear and candidal hyphae may be confirmed by periodic acid-Schiff staining, or in the office by a potassium hydroxide float.

• (ii) Laboratory investigations: These include microbiological testing (i.e., standard culture techniques, or by detecting microbial antigens, antibodies and other immune reactions, or by newer molecular techniques (e.g., 15s ribosomal RNA)), and bloodwork (e.g., complete blood counts, metabolic panels, serological analyses). These investigations are covered in the chapters “Laboratory Medicine and Diagnostic Pathology” and “Clinical Immunology in Diagnoses of Maxillofacial Disease.”

• (iii) Biopsy and histopathological investigation: The definitive diagnosis of many oral and maxillofacial diseases is based on a histopathologic diagnosis. Performing a biopsy of soft tissue lesions requires minimal surgical expertise; however, selecting the biopsy site that will optimally provide representative tissue requires careful consideration because different diseases dictate different sampling techniques. Excisional biopsy is performed when the intent is to remove an entire lesion, while incisional biopsy is indicated when a representative part of a lesion is taken. The tissue sample should be immediately placed into a bottle containing formalin or other appropriate solutions depending on the investigation required and transported to the pathology laboratory along with a requisition form that describes the patient demographics, history, and physical findings including the site of biopsy, and a presumptive/differential diagnosis. These techniques are covered in the chapter “Soft and Hard Tissue Operative Investigations in the Diagnosis and Treatment of Oral Disease.”

Referral/Consultation

It is imperative that oral health-care providers are competent in their ability to communicate and collaborate with other members of the health-care team to facilitate the provision of health care. Medical consultation may be initiated with a patient’s physician or other health-care professionals in the following scenarios: (1) the patient is a poor historian and the medical history is unclear or incomplete; (2) the patient has a severe medical condition which increases the risk of an adverse event (e.g., recent myocardial infarction); (3) the patient has an abnormal review of systems or physical examination/vital signs finding that needs further evaluation (e.g., shortness of breath, pallor, or elevated blood pressure); or (4) when it is necessary to obtain reports of laboratory tests and other investigations required for diagnosis and management. At other times, it may be necessary to refer a patient for evaluation and management of specific clinical problems when the patient’s treatment needs fall outside the treating doctor’s scope of practice. Examples include: (1) patients with extraoral lesions; (2) patients with oral and maxillofacial signs and symptoms suggestive of a systemic disease; and (3) patients requiring specialized interventions such as surgery. It is preferable that referral and consultation requests be made in writing in the form of a report. However, in certain situations, a phone call or text message may be more practical when it is necessary to obtain information immediately. In such circumstances, the phone conversation and messages must be documented afterward. 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 surgery, it is important to communicate the details of the planned procedure, anticipated amount of blood loss if applicable and level of stress to the patient. These medical consultations are made to request additional information concerning the patient that will aid in risk assessment and potential modifications to treatment. Therefore, the final responsibility regarding the risk of treatment lies with the oral health-care provider who must carefully make the final treatment decisions and not the physician (Gary and Glick 2012).

Documentation

Medical records provide information regarding the history of patients’ evaluation and treatment and can serve as useful evidence during lawsuits. Therefore, it is important to maintain accurate well-organized and complete records in a chronological order. In settings where paper-based health records are utilized, it is important to ensure that all pages of the health record contain the patient’s name and identification number. All entries should be legible, dated, and contain the author’s name and identification. Although there is no generally accepted format for documentation of clinical data, it is imperative to carefully record all aspects of the clinical history, physical examination, diagnosis, and treatment plan at every patient encounter (Table 1). Other important components of the medical record, which should be filed in the chart, include laboratory and imaging reports, referral and consultation requests, informed consent, operative notes, postoperative orders, email, text messages, and telephone conversations.

Patients with chronic oral diseases will return for follow-up evaluation and care. An abbreviated history is sufficient and the SOAP format is helpful to update the patient’s history and examination findings since the last visit (subjective, objective, assessment, and plan). “Subjective” refers to the history, “objective” refers to examination findings, “assessment” is the diagnosis along with the disposition of the patient relative to the diagnosis (e.g., lichen planus, significant improvement on topical steroids), and “plan” is the new management plan.

Conclusions and Future Directions

The goal of clinically evaluating oral diseases is to arrive at a definitive diagnosis and provide effective and safe treatment to patients. A careful and systematic approach must be applied to gathering and interpreting the information collected during the medical history and physical examination. Thorough knowledge of the anatomy, physiology, and clinical behavior of oral diseases is essential to make the correct diagnosis. It is extremely important that oral health-care providers are appropriately trained in the diagnosis and management of diseases affecting the oral and maxillofacial region.

Cross-References

• Clinical Evaluation of Orofacial Pain

• Clinical Immunology in Diagnoses of Maxillofacial Disease

• Diagnostic Imaging Principles and Applications in Head and Neck Pathology

• Head and Neck Tumors

• Interface Between Oral and Systemic Disease

• Laboratory Medicine and Diagnostic Pathology

• Odontogenic Pathology

• Oral Mucosal Malignancies

• Oral Ulcerative Lesions

• Oral Vesicular and Bullous Lesions

• Salivary Gland Disorders and Diseases

• Soft and Hard Tissue Operative Investigations in the Diagnosis and Treatment of Oral Disease

• White and Red Lesions of the Oral Mucosa