Examination of the Oral Cavity
Eric T. Stoopler, D.M.D., FDSRCS, FDSRCPSProfessor of Oral Medicine
University of Pennsylvania School of Dental MedicineAttending, Division of Oral Medicine
University of Pennsylvania Health [email protected]
www.aaom.com
Disclosures
• Employment, University of Pennsylvania
• Executive Committee, American Academy of Oral Medicine
• Board of Trustees, American Academy of Oral Medicine
• Textbook preparation, Elsevier, Inc.
• Monograph preparation, Metropolitan Life Insurance Co.
• Course Director, Coursera Online Learning Platform
• Honoraria, Continuing Education
• Become familiar with intraoral and extraoral examination
techniques
• Describe how to document lesions of the oral cavity
• Generate an appropriate differential and working diagnosis
www.cancer.gov
Bruch JM, Treister NS. Eds. Clinical Oral Medicine and Pathology, 2nd Ed., Springer, 2017 Yasney JS, et al. Mt Sinai J Med 2012
• 60% of total mucosa
• Non-keratinized
• Lips, cheeks, alveolar
mucosa, ventral tongue,
floor-of-mouth, soft palate • 25% of total mucosa
• Keratinized
• Gingiva, hard palate
• 15% of total mucosa
• Papillae
• Dorsal tongueCruchley AT, Bergmeier LA. Structure and Functions of the Oral Mucosa. In: L.A. Bergmeier (ed.),
Oral Mucosa in Health and Disease, Springer International Publishing, 2018
Documentation of Oral Lesion(s)
A. Site
• Exact anatomical site(s) the lesion occupies
• Avoid colloquial / layman’s terms
• Ex: Right posterior lateral border of the tongue
Kahn MA, Hall JA (eds.), The ADA Practical Guide to Soft Tissue Oral Disease (2nd Ed.); John Wiley and Sons, 2018.
Documentation of Oral Lesion(s)
B. Morphology
Blisterform – contains fluid
• Vesicle - < 0.5cm
– serum / mucin
• Bulla - > 0.5cm;
– serum / mucin / blood
• Pustule – any size
– contains purulent exudate
Nonblisterform - solid
• Papule - < 0.5cm
• Nodule – 0.5cm - < 2cm
– Sessile – broad-based
– Pedunculated – stalk
• Tumor - > 2cm
• Plaque - > 0.5cm
– “pasted on”
Elevated – surface is above the normal plane of mucosa
Kahn MA, Hall JA (eds.), The ADA Practical Guide to Soft Tissue Oral Disease (2nd Ed.); John Wiley and Sons, 2018.
Documentation of Oral Lesion(s)
B. Morphology
Ulcer
• Number: solitary v. multiple (separate vs. coalesced)
• Outline: regular v. irregular
• Margins: raised v. smooth
• Depth: superficial v. deep
• Diameter: 0.5cm (< or >)
• Scarring / atrophy / pitting / pouching may be present
Depressed – surface is below the normal plane of mucosa
Kahn MA, Hall JA (eds.), The ADA Practical Guide to Soft Tissue Oral Disease (2nd Ed.); John Wiley and Sons, 2018.
Documentation of Oral Lesion(s)
B. Morphology
Macule / Patch (except dorsolateral tongue)
Flat lesion of abnormal color
Macule: < 1.0 cm
Patch: > 1.0 cm
Dorsolateral tongue (Depapillation)
Mimics depressed lesion
Flat – surface is level with the normal plane of mucosa
Kahn MA, Hall JA (eds.), The ADA Practical Guide to Soft Tissue Oral Disease (2nd Ed.); John Wiley and Sons, 2018.
Documentation of Oral Lesion(s)
C. Color
• White
• Pink
• Red
• Red and white
• Blue
• Purple
• Gray
• Yellow
• Brown
• Black
• Translucent
Kahn MA, Hall JA (eds.), The ADA Practical Guide to Soft Tissue Oral Disease (2nd Ed.); John Wiley and Sons, 2018.
Documentation of Oral Lesion(s)
D. Size
• Measured by greatest
dimension in length and
width
• Expressed in metric units
(e.g. cm)
E. Consistency
• Fixed
• Freely moveable
• Indurated
• Firm, doughy, rubbery
• Soft
• Fluid, fluctuant, rebounding
Kahn MA, Hall JA (eds.), The ADA Practical Guide to Soft Tissue Oral Disease (2nd Ed.); John Wiley and Sons, 2018.
Differential Diagnosis
• Generated by patient history and physical exam findings
• Most likely dx (working dx)→ least likely dx
• Definitive dx (diagnostic test results + clinical exam findings)
• Dx algorithms
– Etiology (e.g. infectious vs. immune-mediated)
– Clinical appearance (e.g. white vs. red)
– Location (e.g. tongue vs. hard palate)
– Clinical behavior (e.g. localized acute vs. multiple chronic)
Idahosa CN, Kerr AR. Clinical Evaluation of Oral Diseases. In: Contemporary Oral Medicine, 2017
Idahosa CN, Kerr AR. Clinical Evaluation of Oral Diseases. In: Contemporary Oral Medicine, 2017
Clin
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l Ap
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iffere
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The Concise Oral Examination
www.nidcr.nih.gov
Conclusions
• Develop a consistent approach to physical examination
• Appropriately document lesions of the oral cavity
• Develop an appropriate differential and working diagnosis
based on medical history and physical examination
findings
Thank You
• www.cancer.gov
• Bruch JM, Treister NS. Eds. Normal anatomy. In: Clinical Oral Medicine and Pathology, 2nd Ed., Springer, 2017
• Yasney JS, Herlich A. Perioperative dental evaluation. Mt Sinai J Med 2012; 79: 34-45.
• Cruchley AT, Bergmeier LA. Structure and Functions of the Oral Mucosa. In: L.A. Bergmeier(ed.), Oral Mucosa in Health and Disease, Springer International Publishing, 2018
• Kahn MA, Hall JA (eds.), Soft Tissue Head and Neck Pathology: Description and Documentation. In: The ADA Practical Guide to Soft Tissue Oral Disease (2nd Ed.); John Wiley and Sons, 2018.
• Idahosa CN, Kerr AR. Clinical Evaluation of Oral Diseases. In: Farah CS, et al. (eds.) Contemporary Oral Medicine; Springer International Publishing AG 2017; DOI 10.1007/978-3-319-28100-1_3-1.
• www.nidcr.nih.gov
References