Recognize development of advanced, irreversible, or untreatable oral disease
Identify conditions requiring testing and/or medical referral
Provide baseline for later comparison
Provide legal documentation of patient’s diagnosis and treatment plan
Components of the Examination
Concept of total patient being treated
Examination is all-inclusive
–Physical
–Mental
–Psychological
Routine, thorough examination
Preparation for Examination
Review health histories and record
Examine radiographs
Explain procedures to be performed
Methods of Examination
Visual observation
Palpation
–Digital
–Bidigital
–Bimanual
–Bilateral
____ Palpation of the lip to illustrate the use of a finger and thumb of the same hand.
Bidigital palpation
____Examination of the floor of the mouth by simultaneous palpation with fingers of each hand in apposition.
Bimanual palpation
______Bilateral palpation is used to examine corresponding structures on opposite sides of the body.
Bilateral palpation
A bilateral examination uses two hands at the same time to examine corresponding structures on opposite sides of the body. A bimanual examination uses fingers and thumb from each hand applied simultaneously in coordination.
C) The first statement is true and the second statement is true is the correct answer.
Sequence of Examination
Systematic sequence for examination
Steps for thorough examination
–Extraoral
–Intraoral
The locations of the major____into which the vessels of the facial and oral regions drain.
lymph nodes
The joint is palpated as the patient opens and closes the mouth.
Assessment of the temporomandibular joint.
To observe the posterior third of the tongue and the attachment to the floor of the mouth, hold the tongue with a gauze sponge, retract the cheek, and move the tongue out, first to one side and then the other, as each section of the mucosa is carefully examined.
Examination of the tongue.
Documentation of Findings
Records
History
Location and extent
–Localized
–Generalized
–Single or multiple lesions
____As part of a clinical examination record form, deviations from normal can be drawn to show the location and relative size.
Record form for clinical findings
Physical Characteristics
Size and shape
Color
Surface texture
Consistency
In addition to the exact location, the width and length of a lesion should be recorded. _______ a convenient method.
Use of a probe to measure a lesion.
Morphologic Categories
Elevated lesions
–Blisterform:lesions contain fluid and are usually soft and translucent.
–Nonblisterform: lesions are solid and do not contain fluid.
Depressed lesions :below the level of the skin or mucosa
–Ulcer:the rupture of an elevated lesion
–Erosion Flat lesions:shallow, depressed lesion that does not extend through the epithelium to the underlying tissue.
A tumor is 1 cm or less in width. A nodule is greater than 5 mm but less than 1 cm in diameter.
C) The first statement is false and the second statement is true is the correct answer.
The____lesion has a base as wide as the lesion itself
sessile
the ____ lesion is attached by a narrow stalk or pedicle.
pedunculated
An outer layer, covering, or scab that may have formed from coagulation or drying of blood, serum, pus, or a combination. A ___ may form after a vesicle breaks; for example, the skin lesion of chickenpox is first a macule, then a papule, then a vesicle, and then a ___
crust
____Red area of variable size and shape.
Erythema.
____Growing outward.
Exophytic
____Hardened.
Indurated.
____Resembling a small, nipple-shaped projection or elevation.
Papillary.
___Minute hemorrhagic spots of pinhead to pinpoint size.
Petechiae.
_____ A loose membranous layer of exudate containing organisms, precipitated fibrin, necrotic cells, and inflammatory cells produced during an inflammatory reaction on the surface of a tissue
Pseudomembrane.
___Any mass of tissue that projects outward or upward from the normal surface level.
Polyp
___Marked with points or dots differentiated from the surrounding surface by color, elevation, or texture.
Punctate.
___Bony elevation or prominence usually found on the midline of the hard palate (torus palatinus) and the lingual surface of the mandible (torus mandibularis) in the premolar area.
Torus.
____Rough, wartlike.
Verrucous (verrucose).
Oral cancer Objective:
to detect cancer of the mouth at the earliest possible stage. Discovered later, when cancer extends into adjacent structures and to the lymph nodes of the neck, the prognosis is less favorable. Because the early lesions are generally symptomless, they may go unnoticed and unreported by the patient. Observation by the dentist or dental hygienist, therefore, is the principal method for the detection of oral cancer.
Oral cancer Location:
neoplasms may arise at any site in the oral cavity. The most common sites are the floor of the mouth, the lateral parts of the tongue, the lower lip, and the soft palate complex. Self-examination: although patients may be instructed in self-examination to watch for changes in oral tissues, it is difficult for persons to see their own tissues, particularly the entire floor of the mouth and base of the tongue, by the usual mirror and lighting systems available in a private home. Self-examination needs to be supplemented with professional examination on a scheduled basis.
oral cancer Appearance:
White areas
Red areas
Ulcers
Masses
Pigmentation
Procedures for Follow-Up
as designated by the dentist, a lesion may be biopsied immediately, a cytologic smear may be obtained, or the patient may be referred to various specialists for additional diagnosis and biopsy.
BIOPSY:
Definition. Biopsy is the removal and examination, usually by microscope, of a section of tissue or other material from the living body for the purposes of diagnosis. A biopsy is either excisional, when the entire lesion is removed, or incisional, when a representative section from the lesion is taken.
Indications for biopsy. Any unusual oral lesion that cannot be identified with clinical certainty must be biopsied. Any lesion that has not shown evidence of healing in 2 weeks should be considered malignant until proven otherwise. A persistent, thick, white, hyperkeratotic lesion and any mass (elevated or not) that does not break through the surface epithelium should be biopsied. Any tissue surgically removed should be submitted for microscopic examination.
Cytologic Smear:
Definition: the cytologic smear technique is a diagnostic aid in which surface cells of a suspicious lesion are removed for microscopic evaluation.
Indications for smear technique: in general, a lesion for which a biopsy is not planned may be examined by smear. An exception is a keratotic lesion that is not suitable for exfoliative cytology. A lesion that looks like potential cancer is examined by smear if the patient refuses to have a biopsy specimen taken. A positive report from a smear can be used to convince the patient of the need for treatment or biopsy.
Applications: the smear technique is used for follow-up examination of patients with oral cancer treated by radiation. The treated tissue may heal inadequately and cause persistent ulceration. Cytology is useful for identifying Candida albicans organisms in patients with suspected candidiasis (moniliasis). Cytology may be useful in identifying herpes virus by taking a smear from an intact vesicle. In mass screening programs for cancer detection, smears may be taken. However, all lesions of high suspicion should be referred for biopsy. Research studies to show changes in surface cells, for example, the effects of topical agents, may use a smear technique.
Limitations of smear technique: when a clear-cut lesion, recognized as pathologic, is present, treatment must not be delayed by waiting for cytologic smear analysis. The smear detects only surface lesions. It is difficult or impossible to scrape deep enough to obtain representative cells from a heavily keratinized lesion. Except for candidiasis, treatment cannot be determined by smear technique results only. After a positive smear, a biopsy is needed for definitive diagnosis. Because research has shown that the smear technique is not diagnostically reliable (there can be “false negatives,” which turn out to be positive biopsies), a negative report cannot be considered conclusive.
Exfoliative Cytology
stratified squamous epithelial cells are constantly growing toward the surface of the mucous membrane where they are exfoliated. Exfoliated cells and the cells beneath them are scraped off, and when these cells are prepared on a slide, changes in the cells can be detected by staining and studying them microscopically. The malignant cells stain differently from normal cells and take on unusual, abnormal forms.Procedure: Materials. Gauze sponges, glass microscopic slides with frosted end, plain lead pencil, paper clips, blade to scrape lesion (flexible metal spatula), fixative (70% alcohol), protective mailing container, history form or data sheet. Steps. Prepare materials. Write the patient’s name on the frosted ends of two glass slides (two for each lesion) in pencil, and place a paper clip on the end of one slide to prevent contact between the slides when packaged for mailing to the laboratory. Prepare the lesion. Irrigate the surface to remove debris. Wipe the surface gently with a wet gauze sponge as needed to remove debris or blood. Do not dry. Scrape the lesion. Use a flexible metal spatula. Scrape the entire surface of the lesion firmly several times (all strokes in the same direction). When a wooden tongue depressor is used, it must be wet before taking the sample so the material will not be absorbed into the wood. For intact vesicles, carefully rupture the vesicle so the fluid flows onto the glass slides. Smear the glass slide. Spread the collected material on the glass slide. Start at the center of the clear end of the slide and smear evenly across the surface. Cover an area approximately 20 mm wide. Handle all glass slides by their edges to prevent fingerprints or other contamination. Fix the cells. Immediately, to prevent drying of the cells, place the slide on a flat surface and flood with generous drops of 70% alcohol or use prepared commercial fixative spray. Obtain second smear. Duplicate the previous smear technique. Apply fixing agent immediately. Complete the fixation. Leave slides for 30 minutes. After 20 minutes, tip the slide to let remaining alcohol run off. Air dry where dust or other foreign material cannot contaminate the smear. Prepare history or data sheet. Basic information includes the following: dentist name and address; patient name and address; lesion; description (size, color, location, shape, consistency, and duration); other: additional related clinical findings or pertinent history. Prepare for mailing. Wrap slides to prevent breakage. Pack with the history or data sheet. Mailing containers provided by most laboratories list specific instructions.
Oral cytology technique:
. (A) Tongue is held out with gauze sponge while a metal spatula is used to scrape a lesion. (B) Collected material is spread evenly on a glass slide.
Laboratory Report
Unsatisfactory report
–Classes I to V
Class II: atypical, but not suggestive of malignant cells. Class III: uncertain (possible for cancer). Class IV: probable for cancer. Class V: positive for cancer.
Follow-up: Report of Class IV or V. Refer for biopsy. Report of Class III. Re-evaluate clinical findings; biopsy usually indicated. Report of Class I or II. The patient must not be dismissed until the lesion has healed. When the lesion persists, the dentist either re-evaluates the clinical findings and requests a repeat cytologic smear or preferably performs a biopsy.
Negative report: either biopsy or smear requires careful follow-up when a negative report is obtained for an oral lesion that appears suspicious by clinical examination. False-negative reports are possible; that is, a malignancy may be present but the sample examined in the smear or biopsy may not have included cancerous cells.
