CHRONIC MULTIFOCAL CANDIDIASIS

Patients may present with multiple areas of chronic atrophic candidiasis. These are most often seen in immunocompromised individuals or in patients with predisposing factors such as ill-fitting dentures. The changes frequently affect the dor-

CHRONIC HYPERPLASTIC CANDIDIASIS

Chronic hyperplastic candidiasis (CHC) includes a variety of clinically recognized conditions in which mycelial invasion of the deeper layers of the mucosa and skin occurs, causing a proliferative response of host tissue (Figure 5-20).

ACUTE ATROPHIC CANDIDIASIS

Acute atrophic candidiasis presents as a red patch of atrophic or erythematous raw and painful mucosa, with minimal evidence of the white pseudomembranous lesions observed in thrush. Antibiotic sore mouth, a common form of atrophic candidiasis, should be suspected in a patient who develops symptoms of oral burning, bad taste, or sore throat during or after therapy with broad-spectrum antibiotics. Patients with chronic iron deficiency anemia may also develop atrophic candidiasis (Figure 5-16).
CHRONIC ATROPHIC CANDIDIASIS

ACUTE PSEUDOMEMBRANOUS CANDIDIASIS (THRUSH)

Clinical Features. Thrush is the prototype of the oral infections caused by Candida.It is a superficial infection of the outer layers of the epithelium, and it results in the formation of patchy white plaques or flecks on the mucosal surface (Figure 5-15, A). Removal of the plaques by gentle rubbing or scraping usually reveals an area of erythema or even shallow ulceration. Because of their prevalence, characteristic appearance, and ease of removal, the lesions of thrush are easily recognized, and a diagnosis of thrush is frequently made on the basis of the appearance of the lesion. A smear demonstrating a yeast or myelin is helpful when the diagnosis is uncertain.

Candidiasis

“Candidiasis” refers to a multiplicity of diseases caused by a yeastlike fungus, Candida, and is the most common oral fungal infection in humans. The various diseases are classified in Table 5-1 according to onset and duration (acute or chronic); clinical features, including color (erythematous/atrophic); location (median rhomboid glossitis, denture stomatitis,

INFECTIOUS WHITE LESIONS AND WHITE AND RED LESIONS Oral Hairy Leukoplakia

Oral hairy leukoplakia is a corrugated white lesion that usually occurs on the lateral or ventral surfaces of the tongue in patients with severe immunodeficiency.The most common disease associated with oral hairy leukoplakia is HIV infection.Oral hairy leukoplakia is reported in about 25% of adults with HIV infection but is not as common in HIVinfected children. Its prevalence reaches as high as 80% in patients with acquired immunodeficiency syndrome (AIDS).

Sanguinaria-Induced Leukoplakia

Sanguinaria extract, a mixture of benzophenanthridine alkaloids derived from the common bloodroot plant ( Sanguinaria canadensis ), has been used in oral rinses and toothpaste products since 1982. The most widely used product with Sanguinaria, Viadent, has been shown, through extensive clinical trials, to be effective against plaque buildup and gingivitis.Importantly, sanguinaria extract has also been shown to be carcinogenic in many studies.In 1999, Damm and associatesreported an increased prevalence of leukoplakia of the maxillary vestibule in patients who used sanguinaria-based products on a routine basis.

Nicotine Stomatitis

Nicotine stomatitis (stomatitis nicotina palati, smoker’s palate) refers to a specific white lesion that develops on the hard and soft palate in heavy cigarette, pipe, and cigar smokers. The lesions are restricted to areas that are exposed to a relatively concentrated amount of hot smoke during inhalation. Areas covered by a denture are usually not involved. The lesion has become less common since pipe smoking has lost popularity. Although it is associated closely with tobacco smoking, the lesion is not considered to be premalignant.Interestingly, nicotine

Smokeless Tobacco–Induced Keratosis

Chewing tobacco is an important established risk factor for the development of oral carcinoma in the United States.
Habitually chewing tobacco leaves or dipping snuff results in the development of a well-recognized white mucosal lesion in the area of tobacco contact, called smokeless tobacco keratosis, snuff dipper’s keratosis, or tobacco pouch keratosis.

Actinic Keratosis (Cheilitis)

Actinic (or solar) keratosis is a premalignant epithelial lesion that is directly related to long-term sun exposure.
These lesions are classically found on the vermilion border of the lower lip as well as on other sun-exposed areas of the skin. A small percentage of these lesions will transform into squamous cell carcinoma.Biopsies should be performed on

Chemical Injuries of the Oral Mucosa

Transient nonkeratotic white lesions of the oral mucosa are often a result of chemical injuries caused by a variety of agents that are caustic when retained in the mouth for long periods of time, such as aspirin, silver nitrate, formocresol, sodium hypochlorite, paraformaldehyde, dental cavity varnishes, acidetching materials, and hydrogen peroxide.The white lesions are attributable to the formation of a superficial pseudomembrane composed of a necrotic surface tissue and an inflammatory exudate.
SPECIFIC CAUSATIVE AGENTS

Cheek Chewing

White lesions of the oral tissues may result from chronic irritation due to repeated sucking, nibbling, or chewing.
These insults result in the traumatized area becoming thickened, scarred, and paler than the surrounding tissues.

Frictional (Traumatic) Keratosis CLINICAL FEATURES

Frictional (Traumatic) Keratosis
CLINICAL FEATURES
Frictional (traumatic) keratosis is defined as a white plaque with a rough and frayed surface that is clearly related to an identifiable source of mechanical irritation and that will usually resolve on elimination of the irritant. These lesions may occasionally mimic dysplastic leukoplakia; therefore, careful examination and sometimes a biopsy are required to rule out any atypical changes.

REACTIVE AND INFLAMMATORY WHITE LESIONS Linea Alba (White Line)

REACTIVE AND INFLAMMATORY WHITE LESIONS
Linea Alba (White Line)
As the name implies, linea alba is a horizontal streak on the buccal mucosa at the level of the occlusal plane extending from the commissure to the posterior teeth. It is a very common finding and is most likely associated with pressure, frictional irritation, or sucking trauma from the facial surfaces of the teeth. This alteration was present in about 13% of the population in one study.

Dyskeratosis Congenita

Dyskeratosis congenita, a recessively inherited genodermatosis, is unusual due to the high incidence of oral cancer in young affected adults.It is a rare X-linked disorder characterized by a series of oral changes that lead eventually to an atrophic leukoplakic oral mucosa, with the tongue and cheek most severely affected.

Hereditary Benign Intraepithelial Dyskeratosis

Hereditary benign intraepithelial dyskeratosis (HBID), also known as Witkop’s disease, is a rare autosomal dominant disorder characterized by oral lesions and bilateral limbal conjunctival plaques.

White Sponge Nevus

White sponge nevus (WSN) is a rare autosomal dominant disorder with a high degree of penetrance and variable expressivity; it predominantly affects noncornified stratified squamous epithelium.The disease usually involves the oral mucosa and (less frequently) the mucous membranes of the nose, esophagus, genitalia, and rectum.The lesions of WSN may be present at birth or may first manifest or become more intense at puberty.

HEREDITARY WHITE LESIONS Leukoedema

HEREDITARY WHITE LESIONS
Leukoedema
Leukoedema is a common mucosal alteration that represents a variation of the normal condition rather than a true pathologic change.It has been reported in up to 90% of black adults and up to 50% of black teenagers.The incidence in white persons in different studies is highly variable (10 to 90%).This difference can be attributed to the darker coloration of the mucosa in black persons, rendering the alteration more visible.

RED AND WHITE LESIONS OF THE ORAL MUCOSA

INDRANEEL BHATTACHARYYA, DDS, MSD D ONALD M. COHEN, DMD, MS, MBA S OL SILVERMAN JR., DDS, MS
▼ HEREDITARY WHITE LESIONS
Leukoedema White Sponge Nevus Hereditary Benign Intraepithelial Dyskeratosis Dyskeratosis Congenita

REFERENCES

1. Scully C. Orofacial herpes simplex virus infections. Current concepts in the epidemiology, pathogenesis and treatment. Oral Surg 1989;68:701–10.
2. Levy JA. Three new human herpesviruses (HHV-6, 7 and 8). Lancet 1997;349:558–62.

Mucormycosis

Mucormycosis (phycomycosis) is caused by an infection with a saprophytic fungus that normally occurs in soil or as a mold on decaying food. The fungus is nonpathogenic for healthy individuals and can be cultured regularly from the human nose, throat, and oral cavity. (The organism represents an opportunistic rather than a true pathogen.) Infection occurs in individuals with decreased host resistance, such as those with poorly controlled diabetes or hematologic malignancies, or those undergoing cancer chemotherapy or immunosuppressive drug therapy.
218,219
In the debilitated patient, mucormycosis may appear as a pulmonary, gastrointestinal, disseminated, or rhinocerebral infection.
The rhinomaxillary form of the disease, a subdivision of the rhinocerebral form, begins with the inhalation of the fungus by a susceptible individual. The fungus invades arteries and causes damage secondary to thrombosis and ischemia. The fungus may spread from the oral and nasal region to the brain, causing death in a high percentage of cases. Symptoms include nasal discharge caused by necrosis of the nasal turbinates, ptosis, proptosis secondary to invasion of the orbit, fever, swelling of the cheek, and paresthesia of the face.
ORAL MANIFESTATIONS
The most common oral sign of mucormycosis is ulceration of the palate, which results from necrosis due to invasion of a palatal vessel.The lesion is characteristically large and deep, causing denudation of underlying bone (Figure 4-45). Ulcers from mucormycosis have also been reported on the gingiva, lip, and alveolar ridge. The initial manifestation of the disease may be confused with dental pain or bacterial maxillary sinusitis caused by invasion of the maxillary sinus. The clinician must include mucormycosis in the differential diagnosis of large oral ulcers occurring in patients debilitated from diabetes, chemotherapy, or immunosuppressive drug therapy.
Early diagnosis is essential if the patient is to be cured of this infection. Negative cultures do not rule out mucormycosis because the fungus is frequently difficult to culture from infected tissue; instead, a biopsy must be performed when mucormycosis is suspected. The histopathologic specimen shows necrosis and nonseptate hyphae, which are best demonstrated by a periodic acid–Schiff stain.
TREATMENT
When diagnosed early, mucormycosis may be cured by a combination of surgical débridement of the infected area and systemic administration of amphotericin B for up to 3 months. Proper management of the underlying disorder is an important aspect affecting the final outcome of treatment. All patients given amphotericin B must be closely observed for renal toxicity by repeated measurements of the blood urea nitrogen and creatinine.

Blastomycosis

Blastomycosis is a fungal infection caused by Blastomyces dermatitidis .This dimorphic organism can grow in either a yeast or as a mycelial form. The organism is found as a normal inhabitant of soil; therefore, the highest incidence of this infection is found in agricultural workers, particularly in the middle Atlantic and southeastern portions of the United States. This geographic distribution of the infection has led to the designation by some as “North American blastomycosis.” Infection by the same organism, however, has also been found in Mexico and Central and South Americas.

Histoplasmosis

Histoplasmosis is caused by the fungus Histoplasma capsulatum ,a dimorphic fungus that grows in the yeast form in infected tissue. Infection results from inhaling dust contaminated with droppings, particularly from infected birds or bats. An African form of this infection is caused by a larger yeast, which is considered a variant of H. capsulatum and is called H. duboisii.

THE PATIENT WITH SINGLE ULCERS

The most common cause of single ulcers on the oral mucosa is trauma. Trauma may be caused by teeth, food, dental appliances, dental treatment, heat, chemicals, or electricity (Figure 4–43). The diagnosis is usually not complicated and is based on the history and physical findings. The most important differentiation is to distinguish trauma from squamous cell carcinoma. The dentist must examine all single ulcers for significant healing in 1 week; if healing is not evident in this time, a biopsy should be done to rule out cancer. (Cancer of the mouth is discussed in detail in Chapter 8.)

ORAL MANIFESTATIONS

Lesions of chronic or aggressive recurrent HSV may occur on the lips or intraoral mucosa. Schneidman and colleagues reviewed 18 cases of chronic herpes infection; 7 cases occurred in renal transplant patients, and 8 occurred in patients with 

Herpes Simplex Virus Infection in Immunosuppressed Patients

Immunosuppressed patients may develop an aggressive or chronic form of herpes infection; therefore, herpes simplex infection should be included in the differential diagnosis when immunosuppressed patients develop chronic oral

EROSIVE LICHEN PLANUS

The majority of cases of lichen planus present as white lesions (discussed in detail in Chapter 5). An erosive and bullous form of this disease presents as chronic multiple oral mucosal ulcers. Erosive and bullous lesions of lichen planus occur in the severe form of the disease when extensive degeneration of the basal layer of epithelium causes a separation of the epithelium from the underlying connective tissue.In some cases, the

CHRONIC BULLOUS DISEASE OF CHILDHOOD

CBDC is another blistering disorder, which chiefly affects children below the age of 5 years. It is characterized by the deposition of IgA antibodies in the basement membrane zone,

LINEAR IGA DISEASE

LAD is characterized by the deposition of IgA rather than IgG at the basement membrane zone, and the clinical manifestations may resemble either dermatitis herpetiformis or pemphigoid. The cause of the majority of cases is unknown, but a minority of cases have been drug induced.As in MMP, the antigens associated with LAD are heterogeneous and may be found in either the lamina lucida or lamina densa portions of the basement membrane.

MUCOUS MEMBRANE PEMPHIGOID (CICATRICIAL PEMPHIGOID)

MMP is a chronic autoimmune subepithelial disease that primarily affects the mucous membranes of patients over the age of 50 years, resulting in mucosal ulceration and subsequent scarring. The primary lesion of MMP occurs when autoantibodies directed against proteins in the basement membrane zone,

BULLOUS PEMPHIGOID

BP, which is the most common of the subepithelial blistering diseases, occurs chiefly in adults over the age of 60 years; it is self-limited and may last from a few months to 5 years. BP may be a cause of death in older debilitated individuals.

Subepithelial Bullous Dermatoses

Subepithelial bullous dermatoses are a group of mucocutaneous autoimmune blistering diseases that are characterized by a lesion in the basement membrane zone. The diseases in this group include bullous pemphigoid (BP), mucous membrane (cicatricial) pemphigoid (MMP), linear IgA disease (LAD), chronic bullous dermatosis of childhood (CBDC), and erosive 

PEMPHIGUS VEGETANS

Pemphigus vegetans, which accounts for 1 to 2% of pemphigus cases, is a relatively benign variant of pemphigus vulgaris because the patient demonstrates the ability to heal the denuded areas. Two forms of pemphigus vegetans are recognized: the Neumann type and the Hallopeau type. The Neumann type is more common, and the early lesions are similar to those seen in pemphigus vulgaris, with large bullae and denuded areas. These areas attempt healing by developing vegetations of hyperplastic granulation tissue. In the Hallopeau type, which is less aggressive, pustules, not bullae, are the initial lesions. These pustules are followed by verrucous hyperkeratotic vegetations.

PARANEOPLASTIC PEMPHIGUS

PNPP is a severe variant of pemphigus that is associated with an underlying neoplasm—most frequently non-Hodgkin’s lymphoma, chronic lymphocytic leukemia, or thymoma Castleman’s disease and Waldenströms macroglobulinemia are also associated with cases of PNPP. Patients with this form of pemphigus develop severe blistering and erosions of the mucous membranes and skin. Treatment of this disease is difficult, and most patients die from the effects of the underlying tumor, respiratory failure due to acantholysis of respiratory epithelium, or

THE PATIENT WITH CHRONIC MULTIPLE LESIONS

THE PATIENT WITH CHRONIC MULTIPLE LESIONS
Patients with chronic multiple lesions are frequently misdiagnosed for weeks to months since their lesions may be confused with recurring oral mucosal disorders. The clinician can avoid misdiagnosis by carefully questioning the patient on the initial visit regarding the natural history of the lesions. In recurring disorders such as severe aphthous stomatitis, the patient may experience continual ulceration of the oral mucosa, but individual lesions heal and new ones form. In the

Recurrent Herpes Simplex Virus Infection

Recurrent herpes infection of the mouth (recurrent herpes labialis [RHL]; recurrent intraoral herpes simplex infection [RIH]) occurs in patients who have experienced a previous herpes simplex infection and who have serum-antibody protection against another exogenous primary infection. In otherwise healthy individuals, the recurrent infection is confined to a localized portion of the skin or mucous membranes. Recurrent herpes is not a re-infection but a reactivation of virus that remains latent in nerve tissue between episodes in a

Behçet’s Syndrome

Behçet’s syndrome, described by the Turkish dermatologist Hulûsi Behçet, was classically described as a triad of symptoms including recurring oral ulcers, recurring genital ulcers, and eye lesions. The concept of the disease has changed from a triad of signs and symptoms to a multisystem disorder.

THE PATIENT WITH RECURRING ORAL ULCERS

THE PATIENT WITH RECURRING ORAL ULCERS
Recurring oral ulcers are among the most common problems seen by clinicians who manage diseases of the oral mucosa. There are several diseases that should be included in the differential diagnosis of a patient who presents with a history of recurring ulcers of the mouth, including recurrent aphthous stomatitis (RAS), Behçet’s syndrome, recurrent HSV infection, recurrent erythema multiforme, and cyclic neutropenia.
Recurrent Aphthous Stomatitis

CLINICAL MANIFESTATIONS

The onset of acute forms of ANUG is usually sudden, with pain, tenderness, profuse salivation, a peculiar metallic taste, and spontaneous bleeding from the gingival tissues. The patient commonly experiences a loss of the sense of taste and

Acute Necrotizing Ulcerative Gingivitis

Acute necrotizing ulcerative gingivitis (ANUG) is an endogenous oral infection that is characterized by necrosis of the gingiva. Occasionally, ulcers of the oral mucosa also occur in patients with hematologic disease or severe nutritional deficiencies (see Chapter 16).

Oral Ulcers Secondary to Cancer Chemotherapy

Oral Ulcers Secondary to Cancer Chemotherapy
Chemotherapeutic drugs are frequently used to effect remission of both solid tumors, hematologic malignancies, and bone marrow transplantation. Similar drugs are used for patients with bone marrow transplants. One of the common side effects of the anticancer drugs is multiple oral ulcers. Dentists who practice in hospitals where these drugs are used extensively may see oral ulcers secondary to such drug therapy more frequently than any other lesion described in this chapter.

CLINICAL MANIFESTATIONS

The clinical signs and symptoms of contact oral allergy are nonspecific and are frequently difficult to distinguish from physical irritation. The reaction occurs only at the site of contact and includes a burning sensation or soreness accompanied by erythema, and occasionally the formation of vesicles and ulcers. Burning sensations without the presence of lesions is not a result of contact allergy, and obtaining allergy tests for patients with burning mouth syndrome with normal-appearing mucosa is not indicated.

Contact Allergic Stomatitis

Contact allergy results from a delayed hypersensitivity reaction that occurs when antigens of low molecular weight penetrate the skin or mucosa of susceptible individuals. These antigens combine with epithelial-derived proteins to form haptens that bind to Langerhans’ cells in the epithelium. The Langerhans’

CLINICAL MANIFESTATIONS

General Findings. EM is seen most frequently in children and young adults and is rare after age 50 years. It has an acute or even an explosive onset; generalized symptoms such as fever and malaise appear in severe cases. A patient may be asymptomatic and in less than 24 hours have extensive lesions of the skin and mucosa. EM simplex is a self-limiting form of the disease and is characterized by macules and papules 0.5 to 2 cm in diameter, appearing in a symmetric distribution.

ETIOLOGY

EM is an immune-mediated disease that may be initiated either by deposition of immune complexes in the superficial microvasculature of skin and mucosa, or cell-mediated immunity. Kazmierowski and Wuepper studied specimens of lesions less than 24 hours old from 17 patients with EM; 13 of the 17 had deposition of immunoglobulin (Ig) M and complement (C) 3 in the superficial vessels.

Erythema Multiforme

Erythema multiforme (EM) is an acute inflammatory disease of the skin and mucous membranes that causes a variety of skin lesions—

TREATMENT

Management should be directed toward shortening the course of the disease, preventing postherpetic neuralgia in patients over 50 years of age, and preventing dissemination in immunocompromised patients. Acyclovir or the newer antiherpes drugs valacyclovir or famciclovir accelerate healing and reduce acute pain, but they do not reduce the incidence of postherpetic neuralgia.

LABORATORY FINDINGS

Cytology is a rapid method of evaluation that can be used in cases in which the diagnosis is uncertain. Fluorescent-antibody stained smears using fluorescein conjugated monoclonal antibodies is more reliable than is routine cytology and is positive in

CLINICAL MANIFESTATIONS

General Findings. Chickenpox is a childhood disease characterized by mild systemic symptoms and a generalized intensely pruritic eruption of maculopapular lesions that rapidly develop into vesicles on an erythematous base. Oral vesicles that rapidly change to ulcers may be seen, but the oral lesions are not an important symptomatic, diagnostic, or management problem.

Varicella-Zoster Virus Infection

Varicella zoster (VZV) is a herpesvirus, and, like other herpesviruses, it causes both primary and recurrent infection and remains latent in neurons present in sensory ganglia.
VZV is responsible for two major clinical infections of humans:

HAND-FOOT-AND-MOUTH DISEASE

Hand-foot-and-mouth disease is caused by infection with coxsackievirus A16 in a majority of cases, although instances have been described in which A5, A7, A9, A10, B2, or B5 or enterovirus 71 has been isolated. The disease is characterized by low-grade fever, oral vesicles and ulcers, and nonpruritic macules, papules, and vesicles, particularly on the extensor surfaces of the hands and feet. The oral lesions are more extensive than are those described for herpangina, and

ACUTE LYMPHONODULAR PHARYNGITIS

This is a variant of herpangina caused by coxsackievirus A10. The distribution of the lesions is the same as in herpangina, but

HERPANGINA

Coxsackievirus A4 has been shown to cause a majority of cases of herpangina, but types A1 to A10 as well as types A16 to A22 have also been implicated. Because many antigenic strains of coxsackievirus exist, herpangina may be seen more than once in the same patient. Unlike herpes simplex infections, which occur at a constant rate, herpangina frequently occurs in epidemics that have their highest incidence from June to October. The majority of cases affect young children ages 3 through 10, but infection of adolescents and adults is not uncommon.

Coxsackievirus Infections

Coxsackieviruses are ribonucleic acid (RNA) enteroviruses and are named for the town in upper New York State where they were first discovered. Coxsackieviruses have been separated into two groups, A and B. There are 24 known types of coxsackievirus group A and

TREATMENT

A significant advance in the management of herpes simplex infections was the discovery of acyclovir, which has no effect on normal cells but inhibits DNA replication in HSV-infected cells.

Acyclovir has been shown to be effective in the treatment of primary oral HSV in children when therapy was started in the first 72 hours. Acyclovir significantly decreased days of fever, pain, lesions, and viral shedding.

LABORATORY DIAGNOSIS

The diagnosis of primary herpetic gingivostomatitis is straightforward when patients present with a typical clinical picture of generalized symptoms followed by an eruption of oral vesicles, round shallow symmetric oral ulcers, and acute marginal gingivitis. Laboratory tests are rarely required in these cases. Other patients, especially adults, may have a less typical clinical picture, making the diagnosis more difficult. This is especially important when distinguishing primary herpes from erythema multiforme since proper therapy differs significantly.

CLINICAL MANIFESTATIONS OF PRIMARY ORAL HERPES

The patient usually presents to the clinician with full-blown oral and systemic disease, but a history of the mode of onset is helpful in differentiating lesions of primary HSV infection from other acute multiple lesions of the oral mucosa. The incubation period is most commonly 5 to 7 days but may range from 2 to 12 days.

CLINICAL MANIFESTATIONS OF PRIMARY ORAL HERPES

The patient usually presents to the clinician with full-blown oral and systemic disease, but a history of the mode of onset is helpful in differentiating lesions of primary HSV infection from other acute multiple lesions of the oral mucosa. The incubation period is most commonly 5 to 7 days but may range from 2 to 12 days.

Primary Herpes Simplex Virus Infections

There are approximately 600,000 new cases of primary HSV infections per year in the United States. Primary HSV infection occurs in patients who do not have immunity resulting from previous contact with the virus. HSV is contracted after intimate contact with an individual who has active HSV primary or recurrent lesions. Primary HSV may also be spread by asymptomatic shedders with HSV present in salivary secretions. The majority of oral HSV infections is caused by HSV1, but primary oral HSV2 infections may also occur chiefly as a result of oral-genital contact.

Herpesvirus Infections

There are 80 known herpesviruses, and eight of them are known to cause infection in humans: herpes simplex virus (HSV) 1 and 2, varicella-zoster virus, Cytomegalovirus, Epstein-Barr virus, and human herpesvirus 6 (HHV6). All herpesviruses contain a deoxyribonucleic acid (DNA) nucleus and can remain latent in host neural cells, thereby evading the host immune response.HHV6, a herpesvirus discovered in 1986, has been shown by seroprevalence studies to infect over 80% of the population by adult life. Two variants, HHV6A and HHV6B have been identified.

THE PATIENT WITH ACUTE MULTIPLE LESIONS

The major diseases that cause acute multiple oral lesions include viral stomatitis, allergic reactions (particularly erythema multiforme and contact allergic stomatitis), and

ULCERATIVE,VESICULAR, AND BULLOUS LESIONS

MARTIN S. GREENBERG, DDS
▼ THE PATIENT WITH ACUTE MULTIPLE LESIONS
Herpesvirus Infections Primary Herpes Simplex Virus Infections Coxsackievirus Infections Varicella-Zoster Virus Infection Erythema Multiforme Contact Allergic Stomatitis Oral Ulcers Secondary to Cancer Chemotherapy Acute Necrotizing Ulcerative Gingivitis
▼ THE PATIENT WITH RECURRING ORAL ULCERS

REFERENCES

1. US Department of Health and Human Services. The selection of patients for x-ray examinations: dental radiographic examinations. DHHS Publication FDA 88-8273. Rockville (MD): US Department of Health and Human Services; 1987.
2. Brooks SL, Brand JW, Gibbs SJ, et al. Imaging of the temporomandibular joint. A position paper of the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:609–18.

BENEFITS AND RISKS

In determining whether to order a particular type of imaging, the clinician first must decide what information is needed and whether diagnostic imaging can provide it. If the answer is yes, the next step is to determine the best imaging technique for the situation. It is possible that several techniques could provide the desired data. For example, an expansile lesion in the mandible may be viewed with panoramic radiography, perhaps supplemented with an occlusal view. However, it could also be visualized with plain-film radiography (at variousangles),

Jaw Lesions

The imaging evaluation of jaw lesions may range from a combination of intraoral and panoramic radiography to CT, MRI, US, and/or scintigraphy, depending on the size, location, margins, and behavior of the lesion. For small well-defined lesions occurring in the jaws, standard dental radiography may be adequate to

Disease Entities Affecting Salivary Glands

There are a number of disease entities that can affect the salivary glands: these entities include obstructive, inflammatory,

IMAGING PROTOCOLS Orofacial Pain

IMAGING PROTOCOLS
Orofacial Pain

In deciding whether to use imaging during the assessment of a patient with orofacial pain, the clinician must first obtain enough information from the history and clinical examination to determine the nature and probable cause of the problem and to decide whether imaging will provide any benefits in the diagnosis and management of the patient. In many cases, it may be necessary to rule out the teeth as a source of the pain. Select intraoral and/or panoramic radiography combined with the clinical examination can generally help in this situation.

Contrast-Enhanced Radiography

Radiography with the use of contrast agents is still performed in some facilities, but its usage has decreased significantly with the evolution of advanced imaging techniques. The major contrast-enhanced examinations used in dentistry are arthrography and sialography.

Nuclear Medicine

In radionuclide imaging (nuclear medicine, scintigraphy), a substance labeled with a radioactive isotope is injected intravenously. Depending on the specific material used, the substance will be taken up preferentially by the thyroid (technetium [Tc] 99m–labeled iodine), salivary glands (Tc 99m pertechnetate), or bone (Tc 99m methylene diphosphonate [MDP]). Gallium 67 citrate is also sometimes used to assess infections and inflammation in bone. At various times after radionuclide injection, a gamma camera is used to count the radioactivity in the various organs and tissues of the body and to display the results visually. High concentrations of the isotope show up as “hot spots” and generally indicate high metabolic activity (Figure 3-13). Nuclear-medicine scans are used to assess conditions that may be widespread, such as metastasis to bone or other tissues or such as fibrous dysplasia in an active phase. Unfortunately, areas of dental periapical and peri-

Ultrasonography

Ultrasonography (US) uses the reflection of sound waves to provide information about tissues and their interfaces with other tissues. This is a noninvasive and relatively inexpensive technique for imaging superficial tissues in “real time.” The operator applies a probe over the area of interest and receives information immediately on the computer monitor. In regard to the head and neck region, there has been a great deal of recent interest in the imaging of salivary glands (Figure 3-12).

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) uses electrical and magnetic fields and radiofrequency (RF) pulses, rather than ionizing radiation, to produce an image. The patient is placed within a large circular magnet that causes the hydrogen protons of the body to be aligned with the magnetic field. At this point, energy in the form of RF pulses is added to the system, and the equilibrium is destabilized, with the protons altering their orientation and magnetic moment. After the RF pulse is removed, the protons gradually return to equilibrium, giving up the excess energy in the form of a radio signal that can be detected and converted to a visible image. This return to equilibrium is called relaxation, and the time that it takes is dependent on tissue type. “T1 relaxation” describes the release of energy from the proton to its immediate environment, and “T2 relaxation” designates the interaction between adjacent protons. This whole sequence of applying RF pulses and then picking up the returning signal later is repeated many times in forming the image.

Computed Tomography

Computed tomography (CT) permits the imaging of thin slices of tissue in a wide variety of planes. Most CT is done in the axial plane, and many CT scans also provide coronal views; sagittal slices are less commonly used. During CT scanning, the x-ray source and detectors move around the desired region of the body while the patient lies on a table. Modern generations of CT scanners use a spiral motion of the gantry to produce the x-ray data that are then reconstructed by computer. The operator selects the region of the anatomy and the thickness of the slices of tissue to be scanned, along with the kilovolt and milliampere settings. Slice thickness is usually 10 mm through the body and brain and 5 mm through the head and neck, unless threedimensional reconstruction is anticipated. In such cases, the slice thickness is 1.0 to 1.5 mm in order to provide adequate data.

IMAGING MODALITIES AVAILABLE IN HOSPITALS AND RADIOLOGY CLINICS

While the standard imaging modalities that are available in dental offices will suffice for many of the cases being evaluated in oral medicine, there are situations in which it is appropriate to refer the patient to a hospital or other facility for a specialized imaging procedure.

Conventional Tomography

Plain (or conventional) tomography is a radiographic technique that has been available for many years, generally in institutions such as dental schools or hospitals, due to the size and expense of the equipment. However, tomographic capability has been added to some sophisticated computer-controlled panoramic x-ray machines, making tomography potentially more readily available in dental offices and clinics.

Digital Imaging

While most intraoral radiography is still performed with film as the recording medium, the use of digital imaging techniques is rapidly increasing. Although it is possible to produce a digital image by scanning a film radiograph, that technique does not provide any of the advantages of speed and radiation dose reduction that are available when digital images are acquired directly.

IMAGING MODALITIES AVAILABLE IN DENTAL OFFICES AND CLINICS

Intraoral and Panoramic Radiography
There are a number of imaging modalities that are readily available to the clinician for evaluating patients’ conditions. Virtually every dental office has the equipment to perform intraoral radiography, and many offices also have panoramic x-ray machines. These two types of radiographic equipment will provide the majority of images needed for evaluating patients’ orofacial complaints.

SELECTION CRITERIA

The decision to order diagnostic imaging as part of the evaluation of an orofacial complaint should be based on the principle of selection criteria. Selection criteria are those historical and/or clinical findings that suggest a need for imaging to provide additional information so that a correct diagnosis and an appropriate management plan can be determined. The use of selection criteria requires the clinician to obtain a history, perform a clinical examination, and then determine both the type of additional information required (if any) and the best technique for obtaining this information. The emphasis is on the acquisition of new information that affects the outcome, not just the routine application of a diagnostic modality.

MAXILLOFACIAL IMAGING

MAXILLOFACIAL IMAGING
SHARON L. BROOKS, DDS, MS
▼ SELECTION CRITERIA ▼ IMAGING MODALITIES AVAILABLE IN DENTAL
OFFICES AND CLINICS
Intraoral and Panoramic Radiography Digital Imaging Conventional Tomography
▼ IMAGING MODALITIES AVAILABLE IN HOSPITALS AND RADIOLOGY CLINICS
Computed Tomography Magnetic Resonance Imaging Ultrasonography Nuclear Medicine Contrast-Enhanced Radiography
▼ IMAGING PROTOCOLS
Orofacial Pain Disease Entities Affecting Salivary Glands Jaw Lesions
▼ BENEFITS AND RISKS

REFERENCES

1. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Developing objectives for healthy people 2010. Washington (DC): US Government Printing office. 1998 Sept.

INFORMED CONSENT

Prior consent of the patient is needed for all diagnostic and treatment procedures, with the exception of those considered necessary for treatment of a life-threatening emergency in a comatose patient.

CONFIDENTIALITY OF PATIENT RECORDS

Patients provide dentists and physicians with confidential dental, medical, and psychosocial information on the understanding that this information may be necessary for effective diagnosis and treatment and that the information will remain confidential and will be not released to other individuals without the patient’s specific permission. This information may also be entered into the patient’s record and shared with other clinical personnel involved in the patient’s treatment unless the patient specifically requests otherwise. Patients are willing to share such information with their dentists and physicians only to the extent that the patient believes that this contract is being honored.

CONDITION DIAGRAM

The condition diagram (CD) uses a standardized approach to categorizing and diagramming the clinical data, formulating a differential diagnosis, prevention factors, and

PROBLEM-ORIENTED RECORD

The problem-oriented record (POR) focuses on problems requiring treatment rather than on traditional diagnoses. It stresses the importance of complete and accurate collecting of clinical data, with the emphasis on recording abnormal findings, rather than on compiling the extensive lists of normal and abnormal data that are characteristic of more traditional methods (consisting of narration, checklists, questionnaires, and analysis summaries). Problems can be subjective (symptoms), objective (abnormal clinical signs), or otherwise clinically significant (eg, psychosocial) and need not be described in prescribed diagnostic categories. Once the patient’s problems have been identified, priorities are established for further diagnostic evaluation or treatment of each problem. These decisions (or assessments) are based on likely causes for each problem, risk analysis of the problem’s severity, cost and benefit to the patient as a result of correcting the problem, and the patient’s stated desires. The plan of treatment is formulated as a list of possible solutions for each problem. As more information is obtained, the problem list can be updated, and problems can be combined and even reformulated into recognized disease categories.

Organization

In recent years, educators have explored a number of methods for organizing and categorizing clinical data, with the aim of maximizing the matching of the clinical data with the

THE DENTAL/MEDICAL RECORD: ORGANIZATION, CONFIDENTIALITY, AND INFORMED CONSENT

The patient’s record is customarily organized according to the components of the history, physical examination, diagnostic summary, plan of treatment, and medical risk assessment described in the preceding pages. Test results

ORAL MEDICINE CONSULTATIONS

Both custom and health insurance reimbursement systems recognize the need of individual practitioners to request the assistance of a colleague who may have more experience with the treatment of a particular clinical problem or who has received advanced training in a medical or dental specialty pertinent to the patient’s problem. However, this practice of specialist consultation is usually limited to defined problems, with the expectation that the patient will return to the referring primary care clinician once the nature of the problem has been identified (diagnostic consultation) and appropriate treatment has been prescribed or performed (consultation for diagnosis and treatment). In general, referrals for oral medicine consultation cover the following:

MONITORING AND EVALUATING UNDERLYING MEDICAL CONDITIONS

Several major medical conditions can be monitored by oral health care personnel. Signs and symptoms of systemic conditions, the types of medications taken, and the patient’s compliance with medications can reveal how well a patient’s underlying medical condition is being controlled. Signs of medical conditions are elicited by physical examination, which includes measurements of blood pressure and pulse, or laboratory or

MONITORING AND EVALUATING UNDERLYING MEDICAL CONDITIONS

Several major medical conditions can be monitored by oral health care personnel. Signs and symptoms of systemic conditions, the types of medications taken, and the patient’s compliance with medications can reveal how well a patient’s underlying medical condition is being controlled. Signs of medical conditions are elicited by physical examination, which includes measurements of blood pressure and pulse, or laboratory or

Summary

The following sample evaluation should summarize all pertinent information given in the above text.
A 45-year-old Caucasian female presents for evaluation of a swelling in her lower lip. The swelling has been present for 1 month.

Modification of Dental Care for Medically Complex Patients

Dental care causes changes to the patient’s homeostasis. The results of the microbiologic, physical, and psychological stimuli caused by dental care may be altered by underlying medical conditions. Therefore, modifications necessary for providing safe and appropriate dental care are often determined by underlying medical conditions. A risk assessment needs to be performed to evaluate and determine what modifications should be implemented before, during, and after dental treatment. Different modifications may be necessary at each stage of treatment. For example, antibiotic prophylaxis or steroid replacement may be necessary before treatment,

Medical Risk Assessment

The diagnostic procedures described above are also designed to help the dentist (1) recognize significant deviations from normal general health status that may affect dental treatment, (2) make informed judgments on the risk of dental procedures, and (3) identify the need for medical consultation to provide assistance in diagnosing or treating systemic disease that may be an etiologic factor in oral disease or that is likely to be worsened by the proposed dental treatment. The end point of the diagnostic process is thus twofold, and an evaluation of any special risks posed by a patient’s compromised medical status under the circumstances of the planned anesthetic, diagnostic, or medical or surgical treatment procedures must also be entered in the chart, usually as an addendum to the plan of treatment. This process of medical risk assessment is the responsibility of all clinicians prior to any anesthetic, diagnostic, or therapeutic procedure and applies to outpatient as well as inpatient situations.

FORMULATING A PLAN OF TREATMENT AND ASSESSING MEDICAL RISK Plan of Treatment

The diagnostic procedures (history, physical examination, and imaging and laboratory studies) outlined in the preceding pages are designed to assist the dentist in establishing a plan of treatment directed at those disease processes that have been identified as responsible for the patient’s symptoms. A plan of treatment of this type, which is directed at the causes of the patient’s symptoms rather than at the symptoms themselves, is often referred to as rational, scientific, or definitive (in contrast to symptomatic, which denotes a treatment plan directed at the relief of symptoms, irrespective of their causes).

ESTABLISHING THE DIAGNOSIS

In some circumstances, the diagnosis (ie, an explanation for the patient’s symptoms and identification of other significant disease process) may be self-evident. When clinical data are more complex, the diagnosis may be established by
1. reviewing the patient’s history and physical, radiographic, and laboratory examination data;
2. listing those items that either clearly indicate an abnormality or that suggest the possibility of a significant health problem requiring further evaluation;
3. grouping these items into primary versus secondary symptoms, acute versus chronic problems, and high versus low priority for treatment; and

SPECIALIZED EXAMINATION OF OTHER ORGAN SYSTEMS

The compact anatomy of the head and neck and the close relationship between oral function and  the contiguous nasal, otic, laryngopharyngeal, gastrointestinal, and ocular structures often require that evaluation of an oral problem be combined with evaluation of one or more of these related organ systems. For detailed evaluation of these extraoral systems, the dentist should request that the patient consult the appropriate medical specialist, who is informed of the reason for the consultation. The usefulness of this consultation will usually depend on the dentist’s knowledge of the interaction of the oral cavity with adjacent organ systems, as well as the dentist’s ability to recognize symptoms and signs of disease in the extraoral regions of the head and neck. Superficial inspection of these extraoral tissues is therefore a logical part of the dentist’s examination for the causes of certain oral problems.

LABORATORY STUDIES

It is important to realize the limitations of any laboratory test. There are no tests that can detect “health”; rather, laboratory tests are used to discriminate between the presence or absence of disease or are used as a predictor of disease. The frequency with which a test indicates the presence of a disease is called sensitivity; specificity is the frequency with which a test indicates the absence of the disease.

SUPPLEMENTARY EXAMINATION PROCEDURES

With the information obtained from the history and routine physical examination, a diagnosis can usually be made, or the information can at least provide the clinician with direction for subsequent diagnostic procedures. Additional questioning of the patient or more specialized examination procedures may still be needed to confirm a diagnosis or distinguish between several possible diagnoses. Examples of more specialized physical examination procedures are the charting of dental restorations, caries, and periodontal defects; dental pulp vitality testing; detailed evaluation of salivary gland function

CRANIAL NERVE FUNCTION

In examining patients with oral sensory or motor complaints, it is important to know if there is any objective evidence of abnormality of cranial nerve function that might relate to the patient’s oral symptoms. A definitive answer to this question usually comes from specific testing of cranial nerve function as part of a general physical examination carried out by either the patient’s physician, an internist, or a neurologist. When the results of a neurologist’s examination are not readily available, a cranial nerve examination carried out by the dentist may help direct diagnostic efforts in the interim. The following schema (summarized in Table 2-7) is provided with such circumstances in mind and not as a substitute for a thorough neurologic examination carried out by a skilled specialist. On the other hand, dentists and oral surgeons in hospitals are often responsible for the admitting history and physical examination of their patients. In view of the focus of dentistry, it is logical that the physical examination carried out by a dentist should be complete as far as the head and neck are concerned and should include an assessment of cranial nerve function. The dentist’s professional training and experience give him or her a specialized knowledge of the range of normal oral function, providing a level of accuracy usually not available to one less experienced in the examination of the mouth. For these reasons, instruction and experience in the evaluation of cranial nerve function, particularly as it relates to the oral cavity (eg, cranial nerves V, VII, IX, and XII), are fully justified as part of a dentist’s education.
The routine cranial nerve examination is carried out systematically according to the sequence of nerves (from I to XII). Each examiner will develop a personal routine, but it should always be standardized so that the results of repeated examinations will be comparable. In addition to the standard evaluation described here, there are a number of other techniques of special interest in particular clinical situations.
Cranial Nerve I (Olfactory Nerve). Olfactory nerve function is traditionally tested by closing one of the patient’s nostrils with a finger and asking if the patient can smell a strongly scented volatile substance such as coffee or lemon extract. The test is then repeated for the other nostril. The patient should sniff strongly to draw the volatile molecules well into the nose. This procedure tests for olfactory nerve function only when the nasal airway is patent to the olfactory receptors and when the substance being tested does not produce a response solely on the basis of chemical irritation of nonspecific somatic sensory receptors in the nasal mucosa. Such responses are due to stimulation of branches of the trigeminal nerve. For this reason, substances such as ammonia, perfumes (because of alcoholic content), and onions, although strongly scented, cannot be used to test for olfactory function. A compact “scratch-and-sniff ” test (suitable for clinical use) that uses 50 different microencapsulated olfactory stimulants (the University of Pennsylvania Smell Identification Test [UP-SIT], Sensonics, Inc., Haddon Heights, N.J.) has been developed by the University of Pennsylvania Clinical SmellCRANIAL NERVE FUNCTION
In examining patients with oral sensory or motor complaints, it is important to know if there is any objective evidence of abnormality of cranial nerve function that might relate to the patient’s oral symptoms. A definitive answer to this question usually comes from specific testing of cranial nerve function as part of a general physical examination carried out by either the patient’s physician, an internist, or a neurologist. When the results of a neurologist’s examination are not readily available, a cranial nerve examination carried out by the dentist may help direct diagnostic efforts in the interim. The following schema (summarized in Table 2-7) is provided with such circumstances in mind and not as a substitute for a thorough neurologic examination carried out by a skilled specialist. On the other hand, dentists and oral surgeons in hospitals are often responsible for the admitting history and physical examination of their patients. In view of the focus of dentistry, it is logical that the physical examination carried out by a dentist should be complete as far as the head and neck are concerned and should include an assessment of cranial nerve function. The dentist’s professional training and experience give him or her a specialized knowledge of the range of normal oral function, providing a level of accuracy usually not available to one less experienced in the examination of the mouth. For these reasons, instruction and experience in the evaluation of cranial nerve function, particularly as it relates to the oral cavity (eg, cranial nerves V, VII, IX, and XII), are fully justified as part of a dentist’s education.
The routine cranial nerve examination is carried out systematically according to the sequence of nerves (from I to XII). Each examiner will develop a personal routine, but it should always be standardized so that the results of repeated examinations will be comparable. In addition to the standard evaluation described here, there are a number of other techniques of special interest in particular clinical situations.
Cranial Nerve I (Olfactory Nerve). Olfactory nerve function is traditionally tested by closing one of the patient’s nostrils with a finger and asking if the patient can smell a strongly scented volatile substance such as coffee or lemon extract. The test is then repeated for the other nostril. The patient should sniff strongly to draw the volatile molecules well into the nose. This procedure tests for olfactory nerve function only when the nasal airway is patent to the olfactory receptors and when the substance being tested does not produce a response solely on the basis of chemical irritation of nonspecific somatic sensory receptors in the nasal mucosa. Such responses are due to stimulation of branches of the trigeminal nerve. For this reason, substances such as ammonia, perfumes (because of alcoholic content), and onions, although strongly scented, cannot be used to test for olfactory function. A compact “scratch-and-sniff ” test (suitable for clinical use) that uses 50 different microencapsulated olfactory stimulants (the University of Pennsylvania Smell Identification Test [UP-SIT], Sensonics, Inc., Haddon Heights, N.J.) has been developed by the University of Pennsylvania Clinical Smell

NECK AND LYMPH NODES

Examination of the neck is a natural extension of a routine dental examination and includes examination of the submandibular and cervical lymph nodes (draining the oropharynx and other tissues of the head and neck and anastomosing with lymphatics from the abdomen, thorax, breast, and arm), the midline structures (hyoid bone, cricoid and thyroid cartilages, trachea, and thyroid gland), and carotid arteries and neck veins.
46
(Examination of the submandibular and sublingual salivary glands was described in the preceding section.) With the patient’s neck extended, note the clavicle and the sternomastoid and trapezius muscles, which define the anterior and posterior triangles of the neck. Palpate the hyoid bone, the thyroid and cricoid cartilages, and the trachea, noting any displacement or tenderness. Palpate around the lower half of the sternomastoid muscle, and identify and palpate the isthmus and wings of the thyroid gland below and lateral to the thyroid cartilage, checking for any nodularity, masses, or tenderness. If local or generalized thyroid enlargement is suspected, check to ascertain whether the mass moves up and down with the trachea when the patient swallows. Observe the external jugular vein as it crosses the sternomastoid muscle, and with the patient at an angle of approximately 45˚ to the horizontal, note any distension and or pulsation in the vein. Distension of >2 cm above the sternal notch is abnormal; in severe right-sided heart failure, distension as far as the angle of the mandible may be seen. Place the diaphragm of the stethoscope over the point of the carotid pulse, and listen for bruits or other disturbances of rhythm that may indicate partial occlusion of the carotid artery.
Palpate for lymph nodes in the neck (Figure 2-2), commencing with the most superior nodes and working down to the clavicle. Palpate anterior to the tragus of the ear for preauricular nodes; at the mastoid and base of the skull for

TEMPOROMANDIBULAR JOINT

Observe deviations in the path of the mandible during opening and closing, as well as the range of vertical and lateral movement.
Palpate the joints, and listen for clicking and crepitus during opening and closing of the jaw; use a stethoscope to characterize and locate these sounds accurately. Note any tenderness over the joint or masticatory muscles (temporalis, masseter)

SALIVARY GLANDS

Note any external swelling that may represent enlargement of a major salivary gland. A significantly enlarged parotid gland will alter the facial contour and may lift the ear lobe; an enlarged submandibular salivary gland (or lymph node) may distend the skin over the submandibular triangle. With minimal manipulation of the patient’s lips, tongue, and cheeks, note the presence of any salivary pool, and note whether the mucosa is moist, covered with scanty frothy saliva, or dry.

TONSILS AND OROPHARYNX

Note the color, size, and any surface abnormalities of tonsils and ulcers, tonsilloliths, and inspissated secretion in tonsillar crypts. Palpate the tonsils for discharge or tenderness, and note restriction of the oropharyngeal airway.

TEETH AND PERIODONTIUM

Note missing or supernumerary teeth, mobile or painful teeth, caries, defective restorations, dental arch irregularities, orthodontic anomalies, abnormal jaw relationships, occlusal interferences, the extent of plaque and

GINGIVAE

Observe color, texture, contour, and frenal attachments. Note any ulcers, marginal inflammation, resorption, festooning, Stillman’s clefts, hyperplasia, nodules, swellings, and

FLOOR OF THE MOUTH

With the tongue still elevated, observe the openings of Wharton’s ducts, the salivary pool, the character and extent of right and left secretions, and any swellings, ulcers, or

THE TONGUE

Inspect the dorsum of the tongue (while it is at rest) for any swelling, ulcers, coating, or variation in size, color, and texture. Observe the margins of the tongue and note the distribution of filiform and fungiform papillae, crenations and fasciculations, depapillated areas, fissures, ulcers, and keratotic areas. Note the frenal attachment and any deviations as the patient pushes out the tongue and attempts to move it to the right and left.

HARD PALATE AND SOFT PALATE

Illuminate the palate and inspect for discoloration, swellings, fistulae, papillary hyperplasia, tori, ulcers, recent burns, leukoplakia, and asymmetry of structure or function. Examine the

MAXILLARY AND MANDIBULAR MUCOBUCCAL FOLDS

Observe color, texture, any swellings, and any fistulae. Palpate for swellings and tenderness over the roots of the teeth and for tenderness of the buccinator insertion by pressing

CHEEKS

Note any changes in pigmentation and movability of the mucosa, a pronounced linea alba, leukoedema, hyperkeratotic patches, intraoral swellings, ulcers, nodules, scars, other red or white patches, and Fordyce’s granules. Observe open

LIPS

Note lip color, texture, and any surface abnormalities as well as angular or vertical fissures, lip pits, cold sores, ulcers, scabs, nodules, keratotic plaques, and scars. Palpate upper lip and lower lip for any thickening (induration) or

FACIAL STRUCTURES

Observe the patient’s skin for color, blemishes, moles, and other pigmentation abnormalities; vascular abnormalities such as angiomas, telangiectasias, nevi, and tortuous superficial vessels; and asymmetry, ulcers, pustules, nodules, and swellings. Note the color of the conjunctivae. Palpate the jaws and super-

Head, Neck, and Oral Cavity (Including Salivary Glands Temporomandibular Joint, Lymph Nodes, and Cranial Nerve Function)

The ability to perform a thorough physical examination of the superficial structures of the head, neck, and oral cavity is essential for all dentists and any clinician involved in diagnosing and treating oral disease. This examination should be carried out on all new dental patients and repeated at least yearly on patients of record. To perform this examination procedure successfully, the examiner needs the following:
1. Adequate knowledge of the anatomy of the region to be able to recognize normal structures and their common variations
2. A well-practiced technique for displaying all of the skin and mucosal surfaces of the head, neck, and oral cavity with minimal discomfort to the patient and a routinethat ensures the systematic examination of all the tissues that can be approached in this way
3. Knowledge of the variety of disease processes that can affect the superficial structures of the head, neck, and oral cavity
4. The ability to succinctly record (in writing) both normal and abnormal findings noted during the examination

The order of examination is a matter of individual choice, but an established and reproducible routine is desirable. Ideally, necessary intraoral and bite-wing radiography should be available when the systematic examination of the oral cavity is carried out. Examination gloves, tongue blades or dental hand mirrors, a dental explorer and periodontal probe, gauze pads, a dental chair, a lamp or flashlight (for illuminating the oral cavity), and a stethoscope are the basic equipment needed.
The examination routine encompasses the following eight steps:
1. Note the general appearance of the individual and evaluate emotional reactions and the general nutritional state. Record the character of the skin and the presence of petechiae or eruptions, as well as the texture, distribution, and quality of the hair. Examine the conjunctivae and skin for petechiae, and examine the sclerae and skin for evidence of jaundice or pallor. Determine the reaction of the pupils to light and accommodation, especially when neurologic disorders are being investigated.
2. Palpate for adenopathy. The superficial and the deep lymph nodes of the neck are best examined from behind the patient, with the patients’s head inclined forward sufficiently to relax the tissues overlying the lymph nodes. Look for distention of the superficial veins as well as for evidence of thyroid enlargement (see also the section on neck and lymphnodes). Palpate any swellings, nodules, or suspected anatomic abnormalities.
3. Examine in sequence the inner surfaces of the lips, the mucosa of the checks, the maxillary and mandibular mucobuccal folds, the palate, the tongue, the sublingual space, the gingivae, and then the teeth and their supporting structures. Last, examine the tonsillar and the pharyngeal areas and any lesion, particularly if the lesion is painful. Any noted asymmetry should be investigated further.
4. Completely visualize the smooth mucosal surfaces of the lips, cheeks, tongue, and sublingual space by using two tongue depressors or mirrors. Perform a more detailed examination of the teeth and supporting tissues with the mouth mirror, the explorer, and the periodontal probe.
5. Have the patient extend the tongue for examination of the dorsum; then have the patient raise the tongue to the palate to permit good visualization of the sublingual space. The patient should extend the tongue forcibly out to the right and left sides of the mouth to permit good visualization of the sublingual space and to permit careful examination of the left and right margins. A piece of gauze wrapped lightly around the tip of the tongue helps when manually moving the patient’s tongue. Examine the tonsillar fossae and the oropharynx.
6. Use bimanual or bi-digital palpation for examination of the tongue, cheeks, floor of the mouth, and salivary glands. Palpation is also useful for determining the degree of tooth movement. Two resistant instruments, such as mirror handles or tongue depressors, placed on the buccal and lingual surfaces of the tooth furnish more accurate information than when fingers alone are directly employed.
7. Examine the teeth for dental caries, occlusal relations, possible prematurities, inadequate contact areas or restorations, evidence of food impaction, gingivitis, periodontal disease, and fistulae.
8. After the general examination of the oral cavity has been completed, make a detailed study of the lesion or the area involved in the chief complaint.
A list of normal anatomic structures that may be identified by superficial examination of the head, neck, and oral cavity is provided in Table 2-6. No attempt is made to identify each

BLOOD PRESSURE

Many dental procedures are stressful to the patient and may cause an elevation of the blood pressure (Table 2-4).
Also, accidental intravascular injection or rapid absorption (eg, injection into a venous plexus) of local anesthetics containing epinephrine may cause a transient rise in the blood pressure. Dental treatment for patients with hypertension is discussed in Chapter 13, Disease of the Cardiovascular System. Syncope due to anxiety or medications is usually associated with systemic hypotension.

PULSE RATE AND RHYTHM

Always determine the patient’s pulse rate and rhythm (see Table 2-3). The normal resting pulse rate is between 60 and 100 beats per minute (bpm). A patient with a pulse rate >100 bpm (tachycardia), even considering the stress of a dental office visit,

TEMPERATURE

The dental patient’s temperature should be taken when systemic illness or systemic response secondary to dental infection (eg, bacteremia) is suspected. The normal oral (sublingual) temperature is 37˚C (98.6˚F), but oral temperatures < 37.8˚C (100˚F) are not usually considered to be significant. Studies of sublingual, axillary, auditory canal, and rectal temperatures in elderly patients indicate that these traditionally accepted values differ somewhat from statistically determined values.
32–34

RESPIRATORY RATE

Normal respiratory rate during rest is 14 to 20 breaths per minute. Any more rapid breathing is called tachypnea and may be associated with underlying disease and or elevated temperature.

Vital Signs

Vital signs (respiratory rate, temperature, pulse, and blood pressure) are routinely recorded as part of the examination (Table 2-3). In addition to being useful as an indicator of systemic disease, this information is essential as a

EXAMINATION OF THE PATIENT General Procedure

EXAMINATION OF THE PATIENT
General Procedure
emotional disturbances, history of psychiatric therapy
The examination of the patient represents the second stage of the diagnostic procedure. An established routine is mandatory. A thorough and systematic inspection of the oral cavity and adnexal tissues minimizes the possibility of overlooking previously undiscovered pathologies. The examination is most conveniently carried out with the patient seated in a dental chair, with the head supported. When dental charting is involved, having an assistant record the findings saves time and limits cross-contamination of the chart and pen. Before seating the patient, the clinician should observe the patient’s general appearance and gait and should note any physical deformities or handicaps.

REVIEW OF SYSTEMS

The review of systems (ROS) is a comprehensive and systematic review of subjective symptoms affecting different bodily systems (Table 2–2). The value of performing a ROS together with the physical examination has been well established.
The clinician records both negative and positive responses. Direct questioning of the patient should be aimed at collecting additional data to confirm or rule out those disease processes that have been identified by the clinician as likely explanations for the patient’s symptoms. This type of questioning may also alert the clinician to underlying systemic conditions that were not fully described in the PMH. Furthermore, the ROS will help to monitor changes in medical conditions. The design of the ROS is aimed at categorizing each major system of the body so as to provide the clinician with a framework that incorporates many different anatomic and physiologic expressions reflective of the patient’s medical status. The ROS includes general categories, to allow for completeness of the review. A complete ROS includes the following categories:
1. General 2. Head, eyes, ears, nose, and throat (HEENT) 3. Cardiovascular 4. Respiratory 5. Dermatologic 6. Gastrointestinal 7. Genitourinary 8. Gynecologic 9. Endocrine 10. Musculoskeletal 11. Hematologic-lymphatic 12. Neuropsychiatric
 

Numerous examples can be provided to underscore the importance of the ROS. Seemingly unrelated systemic disorders that significantly affect a patient’s dental care may be disclosed. A woman may disclose a history of hoarseness (throat category), which, when coupled with a history of smoking and neck lymph node examination, may uncover a cancer of the throan. A woman complaining of burning in her mouth might advise her dentist that she is taking a broad-spectrum antibiotic for a urinary tract infection (genitourinary category); this information might allow the dentist to determine that the antibiotic is the underlying cause of an oral fungal infection and to  provide the patient with appropriate care. By carefully questioning the patient about each system listed above (and listed more specifically in Table 2-2), the dental practitioner can assess what the impact of systemic disorders will be on the patient’s dental management.

FAMILY HISTORY

Serious medical problems in immediate family members (including parents, siblings, spouse, and children) should be listed. Disorders known to have a genetic or environmental basis (such as certain forms of cancer, cardiovascular disease including hypertension, allergies, asthma, renal disease, stomach ulcers, diabetes mellitus, bleeding disorders, and sickle cell anemia) should be addressed. Also noted are whether parents, siblings, or offspring are alive or dead; if dead, the age at death and cause of death are recorded. This type of information will alert the clinician to the patient’s predisposition to develop serious medical conditions.

SOCIAL HISTORY

Different social parameters should be recorded. These include marital status (married, separated, divorced, single, or with a “significant other”); place of residence (with family, alone, or in an institution); educational level; occupation; religion; travels abroad; tobacco use (past and present use and amount); alcohol (ETOH) use (past and present use and amount); and recreational drug use (past and present use, type, and amount). When obtaining the social history, the clinician should take into account the patient’s chief complaint and PMH in

PAST MEDICAL HISTORY

The past medical history (PMH) includes information about any significant or serious illnesses a patient may have had as a child or as an adult. The patient’s present medical problems are also enumerated under this category. The PMH is usually organized into the following subdivisions: (1) serious or significant illnesses, (2) hospitalizations, (3) transfusions, (4) allergies, (5) medications, and (6) pregnancy.

PAST DENTAL HISTORY

Despite its frequent omission from the dental record, the past dental history (PDH) is one of the most important components of the patient history. This is especially evident when the patient presents with complicating dental and medical factors such as restorative and periodontal needs coupled with a systemic disorder such as diabetes. Significant items that should be recorded routinely are the frequency of past dental visits; previous restorative, periodontic, endodontic, or

CHIEF COMPLAINT AND HISTORY OF THE PRESENT ILLNESS

The chief complaint is established by asking the patient to describe the problem for which he or she is seeking help or treatment. The chief complaint is recorded in the patient’sown words as much as possible and should not be documented in technical (ie, formal diagnostic) language unless reported in that fashion by the patient; this may give the dentist some insight into the patient’s “dental intelligence quotient.” Patients may or may not volunteer a detailed history of the problem for which they are seeking treatment, and additional information usually needs to be elicited by the examiner. The patient’s responses to these questions constitute the history of the present illness (HPI). A typical description of the chief complaint of a patient presenting for emergency dental care might be the following: This 32-year-old white male presents for emergency dental care, complaining that “I have been having pain in my lower left back tooth for the last 2 weeks, and it needs to be taken out.” Questioning during the HPI will center around the offending tooth in the mandibular left posterior sextant. The astute clinician will note that this patient may not realize that this particular tooth can be retained and can then inform the patient of appropriate treatment options once more historical and diagnostic data have been collected.

BIOGRAPHIC AND DEMOGRAPHIC INFORMATION

The recording of the patient’s name, address, and telephone number; identification number (eg, social security number); age (date of birth); sex; race or ethnicity; name, address, and telephone number of a friend or next of kin; name, address, and telephone number of the referring dentist or physician, as well as that of the physician(s) and dentist(s) whom

Components

The components of a medical history may vary slightly, but most medical histories contain specific information under specific headings. Information on the health of the patient can be arbitrarily divided into objective and subjective information. The objective information consists of an account of the patient’s past medical history, as well as information gained by physical and supplementary examination procedures (ie, signs).

EVALUATION OF THE DENTAL PATIENT:DIAGNOSIS AND MEDICAL RISK ASSESSMENT

EVALUATION OF THE DENTAL
PATIENT:DIAGNOSIS AND
MEDICAL RISK ASSESSMENT

Objectives for the health status of the US population for the early twenty-first century have already been published by the US Department of Health and Human Services.
Three sweeping goals have been introduced: (1) an increase in the span of healthy life; (2) the reduction of health disparities; and (3) universal access to preventive services. These are commendable goals that need to be achieved for a rapidly aging population that is suffering from an increased incidence of medical and physical disabilities requiring improved access to medical services.
The mean age for individuals in the United States in 1998 was 36.2 years, with 12.7% of the population over 65 years of age. However, by 2015, the number of Americans over the age of 65 years will have increased by almost 16%, compared to the number of such Americans in 1998.

MANAGEMENT OF DENTAL PATIENTS WITH SEVERE MEDICAL PROBLEMS

For several reasons, a dentist may choose to hospitalize a patient with severe medical problems. Important considerations are the availability of emergency resuscitation supplies; nursing care before and after the dental procedure; consultations with other medical disciplines; clinical laboratory facilities before and after the dental procedure; and operating rooms and anesthesiologists. Several medical insurance plans now cover hospitalization for patients with severe medical problems who are admitted for dental treatment.

Answering Consultations

There is a standard format that should be followed when answering consultations from other hospital departments. Consultations that are answered only by short phrases such as “denture adjusted” or “tooth extracted” are unsatisfactory since the physician who hospitalized the patient for a medical problem is not given sufficient information. This information may be important in the management of the patient. Below is an uncomplicated consultation concerning a patient who developed dental pain while being hospitalized for a medical problem.

Requesting Information

The standard format used to request medical information from other departments is simple. The difficulty arises in deciding what medical information is necessary for a particular patient. This requires experience as well as knowledge of how a medical problem may change dental treatment.
When requesting information from other departments, it is necessary to write only two or three sentences containing the following data: age and sex of the patient, dental treatment to be performed, and medical information required. A typical consultation request is as follows:

ORAL MEDICINE IN THE HOSPITAL

The hospital is frequently the setting for the most complex cases in oral medicine. Hospitalized patients are most likely to have oral or dental complications of bone marrow transplantation, hematologic malignancies, poorly controlled diabetes, major bleeding disorders, and advanced heart disease. The hospital that wishes to provide the highest level of care for its patients must have a dental department.

THE PRACTICE OF ORAL MEDICINE

The field of oral medicine consists chiefly of the diagnosis and medical management of the patient with complex medical disorders involving the oral mucosa and salivary glands as well as orofacial pain and temporomandibular disorders. Specialists trained in oral medicine also provide dental and oral health care for patients with medical diseases that affect dental treatment, including patients receiving treatment for cancer, diabetes, cardiovascular diseases, and infectious diseases. All dentists receive predoctoral training in these fields, but the complex patient requires a clinician with specialized training in these fields. The American Academy of Oral Medicine defines the field as follows: