Oral Medicine and Pathology at a Glance

By Pedro Diz Dios, Crispian Scully, Oslei Paes de Almeida and 2 more

Oral Medicine and Pathology at a Glance, 2nd Edition offers a comprehensive overview of essential aspects of oral medicine and pathology, with an emphasis on oral health care provision in general practice.

• Updated new edition, covering the most important conditions and commonly encountered oral pathologies and their clinical management
• Presented in the popular, highly-illustrated At a Glance style with clinical photographs throughout
• Written by an international author team
• Includes a companion website with self-assessment MCQs, further reading and downloadable images

• Language: English
• Publisher: Wiley
• Release date: Apr 18, 2017
• ISBN: 9781119121367

Pedro Diz Dios

Pedro Diz Dios is qualified in Medicine and is a Specialist in Stomatology at Santiago de Compostela University (Spain). He trained in Oral and Maxillofacial Surgery at the Freiburg University Hospital (Germany), gaining his Doctor of Philosophy PhD (Freiburg University). He is Professor, Consultant and Head of the Special Needs Unit, School of Medicine and Dentistry, Santiago de Compostela University. He was Director of the Stomatology Department and he is Director of the Master´s Program on “Dental management of patients with systemic diseases” at the Santiago de Compostela University. He is a Council member of the International Association for Disability and Oral Health (IADH). He is an Honorary Visiting Professor at the UCL-Eastman Dental Institute (London). He is Editor in Chief of Special Care in Dentistry, Associate Editor of Oral Diseases Journal, Medicina Oral Cirugía Oral y Patología Bucal, and Journal of Oral and Experimental Dentistry, as well as an Editorial Board Member of Journal of Disability and Oral Health. He has written about 200 peer-reviewed papers and co-authored several books.

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1

Examination of extraoral tissues

This book does not include the basics of history taking, only specific relevant points in the text. Bear in mind that the history gives the diagnosis in about 80% of cases.

Following the history, during which the clinician will note the patient’s conscious level, any anxiety, appearance, communication, posture, breathing, movements, behavior, sweating, weight loss or wasting (Figure 1.1), physical examination is indicated. This necessitates touching the patient; therefore, informed consent and confidentiality are required, a chaperone available, and religious and cultural aspects should be borne in mind (see Scully and Wilson).

Photo of a child with a cerebral palsy head. His mouth is open, displaying his teeth.

Figure 1.1 Cerebral palsy head.

Relevant medical problems may even be manifest in the fully clothed patient – where changes affect the head and neck, cranial nerves, or limbs. Therefore, while there is no rigid system for examination, the clinician should ensure that these areas are checked.

Head and neck

Pupil size should be noted (e.g. dilated in anxiety or cocaine abuse, constricted in heroin abuse).

Facial color should be noted:

pallor (e.g. anemia)

rashes (e.g. viral infections, lupus) (Figure 1.2)

erythema (e.g. anxiety, alcoholism, polycythemia)

Photo of a patient’s closed lips presenting hereditary hemorrhagic telangiectasia.

Figure 1.2 Hereditary hemorrhagic telangiectasia.

Swellings, sinuses or fistulas should be noted (Figure 1.3).

Photo of a man’s chin with a cutaneous odontogenic fistula.

Figure 1.3 Cutaneous odontogenic fistula.

Facial symmetry is examined for evidence of enlarged masseter muscles (masseteric hypertrophy) suggestive of clenching or bruxism.

Neck swellings should be elicited, followed by careful palpation of lymph nodes (and salivary and thyroid glands), searching for swelling and/or tenderness, by observing the patient from in front, noting any obvious asymmetry or swelling (Figure 1.4a and b), then standing behind the seated patient to palpate the nodes. Systematically, each region needs to be examined lightly with the pulps of the fingers, trying to roll the nodes against harder underlying structures.

Photo of a bearded man’s neck displaying lipoma, a lump on the neck near the ear.

Figure 1.4a Lipoma.

Image described by caption.

Figure 1.4b Scan of lipoma (arrow on lesion).

Some information can be gained by the texture and nature of the lymphadenopathy; nodes that are tender may be inflammatory (lymphadenitis), while those that are increasing in size and are hard, or fixed to adjacent tissues, may be malignant.

Cranial nerves

The cranial nerves should be examined, in particular facial movement and corneal reflex should be tested and facial sensation determined (Table 1.1). Movement of the mouth as the patient speaks is important, especially when they allow themselves the luxury of some emotional expression.

Table 1.1 Cranial nerve examination.

Facial movement is tested out by asking the patient to:

close their eyes; any palsy may become obvious, with the affected eyelid failing to close and the globe turning up so that only the white of the eye shows (Bell sign)

close their eyes tightly against your attempts to open them, and note the degree of force required to part the eyelids

wrinkle their forehead, and check any difference between the two sides

smile

bare the teeth or purse the lips

blow out the cheeks

whistle

The muscles of the upper face (around the eyes and forehead) are bilaterally innervated and thus loss of wrinkles on one-half of the forehead or absence of blinking suggests a lesion in the lower motor neurone.

Corneal reflex depends on the integrity both of the trigeminal and facial nerves – a defect of either will give a negative response. This is tested by gently touching the cornea with a wisp of cotton wool twisted to a point. Normally, this procedure causes a blink but, provided that the patient does not actually see the cotton wool, no blink follows if the cornea is anesthetic from a lesion involving the ophthalmic division of the trigeminal nerve, or if there is facial palsy.

Facial sensation is tested by determining the response to light touch (cotton wool) and pin–prick (gently pricking the skin with a sterile pin, probe or needle without drawing blood). It is important to test sensation in all parts of the facial skin but the most common defect is numb chin, due to a lesion affecting the mandibular division of the trigeminal.

Occasionally, a patient complains of hemifacial or complete facial hypoesthesia (reduced sensation) or anesthesia (complete loss of sensation). If the corneal reflex is retained or there is apparent anesthesia over the angle of the mandible (an area not innervated by the trigeminal nerve), then the symptoms are probably functional (non-organic, i.e. psychogenic).

Limbs

Hands may reveal rashes (Figure 1.5), purpura (Figure 1.6), pigmentation or conditions such as arthritis and Raynaud phenomenon. Finger clubbing may reveal systemic disease. Nail changes may reveal anxiety (nail biting), or disease such as koilonychia (spoon-shaped nails), in iron deficiency.

Photo of the same patient in Figure 1.2 displaying her palms with hereditary hemorrhagic telangiectasia.

Figure 1.5 Hereditary hemorrhagic telangiectasia (same patient as in Figure 1.2).

Photo of a portion of an arm with purpura, a dark spot on the skin.

Figure 1.6 Purpura on arm.

The operator should then ensure that all relevant oral areas are examined, in a systematic fashion.

Reference

Scully C and Wilson N (2006). Culturally Sensitive Oral Healthcare. Quintessence, London.

2

Examination of mouth, jaws, temporomandibular region and salivary glands

The lips are best first inspkected. Complete visualization intraorally requires a good light; this can be a conventional dental unit light, or special loupes or ENT light (Figures 2.1a and b). If the patient wears a dental appliance, this should be removed to examine beneath.

Photo of a man with surgical mask wearing a portable miniature operative light mounted on his eyeglasses.

Figure 2.1a Portable miniature operative light.

Photo of an ENT headlight.

Figure 2.1b ENT headlight.

Mouth

The dentition and occlusion should be examined. Study models on a semi- or fully-adjustable articulator may be needed. This is discussed in basic dental textbooks.

All mucosae should be examined, beginning away from the focus of complaint or location of known lesions. Labial, buccal, floor of the mouth, ventrum of tongue, dorsal surface of tongue, hard and soft palate mucosae, gingivae and teeth should be examined in sequence, recording lesions on a diagram (Figures 2.2a–f). Lesions are described as in Table 2.1.

Photo of maxillary teeth and gingivae.

Figure 2.2a Teeth and gingivae.

Photo of a portion of the right-side buccal mucosa.

Figure 2.2b Buccal mucosa.

Photo of a portion of the left-side buccal mucosa.

Figure 2.2c Buccal mucosa.

Photo of a palate.

Figure 2.2d Palate.

Photo of tongue dorsum.

Figure 2.2e Tongue dorsum.

Photo of tongue ventrum and floor of mouth.

Figure 2.2f Tongue ventrum and floor of mouth.

Table 2.1 Main descriptive terms applied to orofacial and skin lesions.