extraoral and intraoral examination

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Chapter 12

Extraoral and Intraoral Examination

Chapter OutlineRationale ComponentsLandmarksSequenceMorphologic CategoriesOral CancerBiopsy DeterminationDocumentationEveryday EthicsFactors to Teach the Patient

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Rationale for ATIONALEINTRAORAL EXAMINATIONCOMPONENTS OF EXAMINATIONI. Types of ExaminationsII. Methods for ExaminationIII. Signs and SymptomsIV. Preparation for ExaminationANATOMICAL LANDMARKSOF THE ORAL CAVITYI. Oral MucosaSEQUENCE OF EXAMINATIONI. Extraoral ExaminationII. Intraoral ExaminationIII. Documentation of FindingsMORPHOLOGIC CATEGORIESI. Elevated LesionsII. Depressed LesionsIII. Flat LesionsIV. Other Descriptive TermsORAL CANCERI. LocationII. Appearance of Early CancerPROCEDURE FOR DETERMINING WHEN ASUSPICIOUS LESION REQUIRES A BIOPSYI. Exfoliative CytologyII. SpectroscopyIII. BiopsyDOCUMENTATIONEVERYDAY ETHICSFACTORS TO TEACH THE PATIENTREFERENCESChapter Outline12LEARNING OBJECTIVES2

Learning ObjectivesExplain the rationaleExplain the systematic sequenceIdentify normal anatomyDescribe physical characteristicsIdentify suspicious conditions

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After studying this chapter, the student will be able to:1. Explain the rationale for a comprehensive extra- andintraoral examination.2. Explain the systematic sequence of the extra- and intraoralexamination.3. Identify normal hard and soft tissue anatomy of the head,neck, and oral cavity.4. Describe and document physical characteristics (size,shape, color, texture, consistency) and morphologicalcategories (elevated, flat, and depressed lesions) for notablefindings.5. Identify suspected conditions that require3

Rationale For The Extraoral And Intraoral Examination

Early identificationTo detect cancerThyroid disordersEating disordersNutritional deficienciesSexually transmitted diseases Systemic conditions 4

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RATIONALE FOR THE EXTRAORALAND INTRAORAL EXAMINATION The extraoral and intraoral examination is performed forearly identification of abnormalities and pathologies, especiallyoral cancer.Although an essential goal of the examination is to detectcancer of the mouth at the earliest possible stage, athorough examination may also reveal signs of thyroid disorders,eating disorders, nutritional deficiencies, sexuallytransmitted diseases, and a host of systemic conditions.14

Components of the ExaminationConcept of total patient being treatedExamination is all-inclusivePhysicalMentalPsychologicalRoutine, thorough examinationAssessment of health-related risk factors5

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5 being treated, not only the oral cavity, and particularlynot just the teeth and immediate surrounding tissues. The examination is all-inclusive to detect possiblephysical or psychological influences on the patientsoral health. Thorough examination is essential for each continuingcare appointment so that the treatment for the controland prevention of oral diseases will be effective. Assessment of health-related risk factors such as:1 Tobacco Alcohol use Cultural and genetic susceptibility Sun exposure and lack of use of sun protection Diet Certain surgeries such as organ or bone marrowtransplant and subsequent long-term immunosuppressivemedications increase the risk of cancer.1 Sexual behaviors involving orogenital contactmay increase risk of human papillomavirus (HPV)transmission and must also be considered withinassessment.1,2

I. Types of Examinations Complete Screening Limited examination Follow- upContinuing care/reevaluation6

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Complete A complete examination includes a thorough summaryof all the components of the assessment. The extraoral and intraoral examination is a componentof a patients complete assessment and isperformed for all new patients and at each routinecontinuing care visit. Screening Screening implies a brief, preliminary examination,usually for a particular purpose such as pain relief orfor initial patient assessment and triage to determinepriorities for treatment. Limited examination A type of brief examination made for an emergencysituation. It may be used in the management of anacute condition. Follow-up Brief follow-up examination to check the healingfollowing a treatment. Continuing care/reevaluation Maintenance after a specific period of time followingthe completion of the care plan and the anticipatedrestoration to health. A maintenance examination is a complete reassessmentfrom which a new dental hygiene diagnosisand care plan are derived.6

II. Methods for ExaminationVisual examinationPalpationInstrumentationPercussionElectrical testAuscultation

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by various visual and tactile, manual, and instrumentalmethods. Patient position, optimum lighting, and effectiveretraction for accessibility and visibility contribute tothe accuracy and completeness of the examination.Visual examination Direct observation : Visual observation is carried outin a systematic sequence to note surface appearance(color, contour, size) and to observe movement andother evidence of function. Radiographic examination : The use of radiographs canreveal deviations from the normal not noticeable bydirect vision. Transillumination : A strong light directed through asoft tissue or a tooth to enhance examination is usefulfor detecting irregularities of the teeth and locatingcalculus. Hold the mouth mirror to view fromthe lingual to see the translucency.Palpation Palpation is examination using the sense of touch throughtissue manipulation or pressure on an area with the glovedfingers of one hand or both. Digital: The use of a single finger. Example: Indexfinger applied to the lingual side of the mandiblebeneath the canine and premolar area to determinepresence of a torus mandibularis. Bidigital: The use of finger and thumb of same hand.Example: palpation of the lips ( Figure 12-1) . Bimanual: The use of finger or fingers and thumbfrom each hand applied simultaneously in coordination.Example: index finger of one hand palpates onthe floor of the mouth inside, while a finger or fingersfrom the other hand press on the same area fromunder the chin externally ( Figure 12-2A and B) . Bilateral: The two hands are used at the same time toexamine corresponding structures on opposite sidesof the body. Comparisons can be made. Example:fingers placed beneath the chin to palpate the submandibularlymph nodes ( Figure 12-3). Instrumentation Examination instruments, such as a periodontalprobe and an explorer, are used for specific examinationof the teeth and periodontal tissues. The use ofprobe and explorer is described in Chapter 16. Percussion Percussion is the act of tapping a surface or toothwith the fingers or an instrument. Information about the status of health is determinedeither by the response of the patient or by the sound.When a tooth is known to be sensitive in any way,percussion needs to be avoided.

Electrical test An electric pulp tester may be used to detect thepresence or absence of vital pulp tissue. Methods for use of a pulp tester are described inChapter 18. Auscultation Auscultation is the use of sound. Example: The sound of clicking of the temporomandibularjoint when the jaw is opened and closed.Figure 12-4 shows examination of the temporomandibularjoint.7

FIGURE 12-1 Bidigital Palpation8

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FIGURE 12-1 Bidigital Palpation> Palpation of the lip to illustrate the use of a fingerand thumb of the same hand8

FIGURE 12-2 Bimanual Palpation. A: Examination of the buccal mucosa by simultaneouspalpation on extraorally and intraorally. B: Examination of the floor of themouth by simultaneous palpation with fingers of each hand in apposition9

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FIGURE 12-4 Assessment of the Temporomandibular Joint10

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FIGURE 12-4 Assessment of the Temporomandibular Joint. The joint is palpated asthe patient opens and closes the mouth.10

III. Signs and SymptomsSignsObjective SymptomsSubjective

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A specific objective for patient examination as a partof the complete assessment is the recognition of deviationsfrom normal that may be signs or symptoms ofdisease. General signs and symptoms may occur in various diseaseconditions. Example: fever, or increase in body

A pathognomonic sign or symptom is unique to a particulardisease and may be used to distinguish that conditionfrom other diseases or conditions.A. Signs A sign is any abnormality identified by a healthcareprofessional while examining a patient. A sign is an objective symptom. Examples of signs: observablechanges such as color, shape, consistency, or abnormalfindings revealed by the use of a probe, explorer,radiograph, or other instrument for disease detection.B. Symptoms A symptom is any departure from normal that may beindicative of disease. It is a subjective abnormality that can be observed bythe patient. Examples are pain, tenderness, and bleeding whentoothbrushing as described by the patient.temperature accompanies most infections.11

IV. Preparation for Examination Review the patients histories Examine radiographs Patient understanding Cultural sensitivity12

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Review the patients health histories and dental/medicalrecord, including risk factors, radiographs, dentalcaries, periodontal, and oral cancer risk assessments. Examine radiographs on viewbox or in the computer. Explain the procedures to be performed and relevanceof the procedures. Example: I am going to perform an extra/intra oralexamination to look for abnormalities that can affectyour oral and overall health. Patient understanding the rational for an extraoraland intraoral examination is critical to acceptanceand education. When a patient is wearing a scarf or other head/neckcovering for cultural or religious purposes, the dentalhygienist uses culturally sensitive communicationskills (Chapter 3).12

Anatomical Landmarks Of The Oral CavityOral MucosaMasticatory MucosaLining MucosaSpecialized Mucosa13

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Familiarization with the structures (Box 12-1, Figures 12-512-7) common to normal anatomy is prerequisite to understanding abnormal presentations in the head andneck region.1I. Oral MucosaThe lining of the oral cavity, the oral mucosa, is a mucousmembrane composed of connective tissue covered withstratified squamous epithelium. There are three divisionsor categories of oral mucosa.A. Masticatory Mucosa Covers the gingiva and hard palate, the areas most usedduring the mastication of food. Except for the free margin of the gingiva, the masticatorymucosa is firmly attached to underlying tissues. The normal epithelial covering is keratinized.B. Lining Mucosa Covers the inner surfaces of the lips and cheeks, floorof the mouth, underside of the tongue, soft palate, andalveolar mucosa. These tissues are not firmly attached to underlyingtissue. The epithelial covering is not keratinized.C. Specialized Mucosa Covers the dorsum (upper surface) of the tongue. Composed of many papillae; some contain taste buds. The distribution of the four types of papillae is shownin Figure 12-5. Filiform: threadlike keratinized elevations that coverthe dorsal surface of the tongue; they are the mostnumerous of the papillae. Fungiform: mushroom-shaped papillae interspersedamong the filiform papillae on the tip and sides ofthe tongue, appear redder than the filiform papillae,and contain variable numbers of taste buds. The insetenlargement in Figure 12-5 shows the comparativeshape and size of the filiform and fungiform papillae. Circumvallate (vallate): the 1014 large round papillaearranged in a V between the body of the tongueand the base. Taste buds line the walls. Foliate: vertical grooves on the lateral posterior sidesof the tongue; also contain taste buds.13

FIGURE 12-6 Anatomical Landmarks of the Oral Cavity-Dorsal Tongue View. A: View of hard and soft palate. B: View of uvula and oro-pharynx.14

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FIGURE 12-6 Anatomical Landmarks of the Oral Cavity-Dorsal Tongue View. A: View of hard and soft palate. B: View of uvula and oro-pharynx.14

Sequence of Examination

Overall appraisal of patientFaceSkinEyesNodesGlandsTemporomandibular jointLips15

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Sequence of Examination Conducting an examination with routine order willminimize the possibility of excluding areas and overlookingdetails of importance. A systematic sequenceimproves efficiency, promotes professionalism, and inspirespatient confidence. A recommended sequence for examination is outlinedin Box 12-1 in which factors to consider during appointmentsare related to the actual observations madeand recorded. This sequence is adapted from Detecting Oral Cancer,available from the National Institutes of Health andthe National Cancer Institute.4,5 In addition to proper sequence, familiarization ofanatomical structures common to normal anatomyis critical to understanding abnormal findings(Table 12-1).315

Sequence of Examination

Breath odorLabial and buccal mucosaTongueFloor of mouthSalivaHard palateSoft palate, uvulaTonsillar region, throat

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FIGURE 12-7 Anatomical Landmarks of the Oral Cavity-Ventral Tongue View17

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FIGURE 12-7 Anatomical Landmarks of the Oral Cavity-Ventral Tongue View.17

Lymph Nodes18

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FIGURE 12-8 Lymph Nodes. The locations of the major lymph nodes into which thevessels of the facial and oral regions drain18

I. Extraoral Examination

. Observe patient during reception and seating to notephysical characteristics and abnormalities, and make anoverall appraisal.2. Observe head, face, eyes, and neck, and evaluate theskin of the face and neck.3. Request the patient remove prosthesis prior to performingthe intraoral examination. Explain how this willimprove the ability to inspect all areas of the mouthadequately.4. Palpate the salivary glands and lymph nodes. Figure 12-8shows the location of the major lymph nodes of the face,oral regions, and neck. Palpation is a significant componentof the extra-/intraoral examination (Figure 12-9).19

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I. Extraoral Examination1. Observe patient during reception and seating to notephysical characteristics and abnormalities, and make anoverall appraisal.2. Observe head, face, eyes, and neck, and evaluate theskin of the face and neck.3. Request the patient remove prosthesis prior to performingthe intraoral examination. Explain how this willimprove the ability to inspect all areas of the mouthadequately.4. Palpate the salivary glands and lymph nodes. Figure 12-8shows the location of the major lymph nodes of the face,oral regions, and neck. Palpation is a significant componentof the extra-/intraoral examination (Figure 12-9).Note any of the following symptoms or experiences: Pain or discomfort upon palpation and/or uponswallowing. Persistent difficulty swallowing in the absence of pain. Any recent noticeable lumps the patient may haveexperienced without pain. Persistent earache or hoarseness of voice.65. Observe mandibular movement and palpate the temporomandibularjoint (Figure 12-4). Relate to itemsfrom questions in the medical/dental history.7,819

I. Extraoral ExaminationPain or discomfort upon palpation and/or uponswallowing.Persistent difficulty swallowing in the absence of pain.Any recent noticeable lumps the patient may haveexperienced without pain.Persistent earache or hoarseness of voice.Observe mandibular movement and palpate TMJ

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II. Intraoral ExaminationLips & intraoral mucosaView/palpate lips, labial and buccal mucosa, and mucobuccal folds.Examine and palpate the tongueMucosa of the floor of the mouth. Hard and soft palates, tonsillar areas, and pharynx Use a mirror oropharynx, nasopharynx, and larynx.6. Note amount and consistency of the saliva and evidence of dry mouth (xerostomia).

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1. Make a preliminary examination of the lips and intraoralmucosa by using a mouth mirror or a tongue depressor(Figure 12-10).2. View and palpate lips, labial and buccal mucosa, andmucobuccal folds.3. Examine and palpate the tongue, including the dorsaland ventral surfaces, lateral borders, and base. Retractto observe posterior third, first to one side then theother ( Figure 12-11).4. Observe mucosa of the floor of the mouth. Palpate thefloor of the mouth ( Figure 12-2B) .5. Examine the hard and soft palates, tonsillar areas, andpharynx ( Figure 12-7A and B). Use a mirror to observethe oropharynx, nasopharynx, and larynx.6. Note amount and consistency of the saliva and evidenceof dry mouth (xerostomia).21

Documentation of Findings

A. HistoryB. Location and ExtentC. Physical Characteristics22

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II. Documentation of FindingsA. HistoryQuestions directed to the patient provide necessary informationin the management of an oral lesion. Becausealarming the patient must be avoided, judgment is neededfor selecting the appropriate time to obtain the history ofa lesion. Whether the lesion is known or not known to thepatient; previous evaluation. If known, when first noticed; if recurrence, previousdate. Duration, symptoms, changes in size and appearance.B. Location and Extent When a lesion is first seen, its location is noted in relationto adjacent structures. Document a complete description of each finding includingthe location, extent, size, color, surface textureor configurations, consistency, morphology, and history. A printed diagram of parts of the oral cavity drawn intothe record form can be a valuable aid for marking thelocation (Figure 12-12).9 Descriptive words to define the location and extent includethe following: Localized: Lesion limited to a small focal area. Generalized: Involves most of an area or segment. Single lesion: One lesion of a particular type with adistinct margin. Multiple lesions: More than one lesion of a particulartype. Lesions may be: Separate: discrete, not running together; may bearranged in clusters. Coalescing: close to each other with margins thatmerge.C. Physical Characteristics Size and shape Record length and width in millimeters. The height of an elevated lesion may be significant. Use a probe to measure, as shown in Figure 12-12. Color Red, pink, white, and red and white are the mostcommonly seen. Other more rare lesions may be blue, purple, gray,yellow, black, or brown. Surface texture A lesion may have a smooth or an irregular surface.22

Morphologic CategoriesElevated LesionsBlisterformVesiclePustuleBulla NonblisterformPapuleNoduleTumorPlaque

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Most lesions can be classified readily as elevated, depressed,or flat as they relate to the normal level of theskin or mucosa. Flowcharts Figures 12-13A elevated lesions, Figure12-13B depressed lesions, and Figure 12-13C flatlesions break down the terms used for describing lesionsin each category.I. Elevated Lesions (Figure 12-13A) An elevated lesion is above the plane of the skin ormucosa. Elevated lesions are considered blisterform ornonblisterform. BlisterformBlisterform lesions contain fluid and are usually soft andtranslucent. They may be vesicles, pustules, or bullae. Vesicle: A vesicle is a small (1 cm or less in diameter),circumscribed lesion with a thin surface covering. Itmay contain serum or mucin and appear white. Pustule: A pustule may be more or less than 5 mmin diameter. It contains pus. Pus gives the pustule ayellowish color. Bulla: A bulla is large (more than 1 cm). It is filledwith fluid, usually mucin or serum, but may containblood. The color depends on the fluid content

NonblisterformNonblisterform lesions are solid and do not contain fluid.They may be papules, nodules, tumors, or plaques. Papules,nodules, and tumors are also characterized by the base orattachment. As shown in Figure 12-14, the pedunculated lesion is attached by a narrow stalk or pedicle, whereas thesessile lesion has a base as wide as the lesion itself. Papule: A papule is a small (pinhead to 5 mm in diameter),solid lesion that may be pointed, rounded,or flat topped. Nodule: A nodule is larger than a papule (greaterthan 5 mm but less than 1 cm). Tumor: A tumor is 2 cm or greater in width. In thiscontext, tumor means a general swelling or enlargementand does not refer to neoplasm, eitherbenign or malignant. Plaque: A plaque is a slightly raised lesion with abroad, flat top. It is usually larger than 5 mm in diameter,with a pasted on appearance23

II. Depressed LesionsUlcerLoss of continuity of epitheliumErosionShallowDoes not extend through epithelium to underlying tissue

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(Figure 12-13B)A depressed lesion is below the level of the skin or mucosa.The outline may be regular or irregular, and there may be aflat or raised border around the depression. The depth canbe described as superficial or deep. A deep lesion is greaterthan 3 mm deep. UlcerMost depressed lesions are ulcers and represent a loss ofcontinuity of the epithelium. The center is often grayto yellow, surrounded by a red border. An ulcer mayresult from the rupture of an elevated lesion (vesicle,pustule, or bulla). ErosionAn erosion is a shallow, depressed lesion that doesnot extend through the epithelium to the underlyingtissue.24

III. Flat LesionsMaculeCircumscribedNot elevated above surrounding skin or mucosaIdentified by color25

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III. Flat Lesions (Figure 12-13C)A flat lesion is on the same level as the normal skin or oralmucosa. Flat lesions may occur as single or multiple lesionsand have a regular or irregular form. A macule is a circumscribed area not elevated above thesurrounding skin or mucosa. It may be identified by its color, which contrasts withthe surrounding normal tissues.25

IV. Other Descriptive TermsCrustErythemaInduratedPapillary PetechiaePseudomembranePolypPunctateTorusVerrucous26

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IV. Other Descriptive Terms Crust: An outer layer, covering, or scab that may haveformed from coagulation or drying of blood, serum, orpus, or a combination. A crust may form after a vesiclebreaks; for example, the skin lesion of chicken pox is firsta macule, then a papule, then a vesicle, and then a crust. Erythema: Red area of variable size and shape. Exophytic: Growing outward. Indurated: Hardened. Papillary: Resembling a small, nipple-shaped projectionor elevation. Petechiae: Minute hemorrhagic spots of pinhead to pinpointsize. Pseudomembrane: A loose membranous layer of exudatecontaining organisms, precipitated fibrin, necroticcells, and inflammatory cells produced during an inflammatoryreaction on the surface of a tissue. Polyp: Any mass of tissue that projects outward or upwardfrom the normal surface level. Punctate: Marked with points or dots differentiated fromthe surrounding surface by color, elevation, or texture. Torus: Bony elevation or prominence usually found onthe midline of the hard palate (torus palatinus) and thelingual surface of the mandible (torus mandibularis) inthe premolar area. Verrucous (verrucose): Rough, wartlike.26

Oral CancerLocationAppearance of Early CancerLeukoplakiaRed areasVelvetyErythroplakiaUlcersMassesPigmentation

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The oral cavity, pharynx larynx, paranasal sinuses andnasal cavity, and salivary glands are regions of the headand neck where cancer can begin.11 Cancers of the head and neck begin in the squamouscells that line moist, mucosal surfaces of the mouth,nose, and throat.2,12 Salivary glands contain different types of cells thatcan also become cancerous.2,12 Because the early lesions are generally symptomless,they may go unnoticed and unreported by the patient.Observation by the dentist or dental hygienist is theprincipal method for the detection of oral cancer. The first step is to examine the entire face, neck, andoral mucous membrane of each patient at the initialexamination and at each continuing care appointment(Table 12-1). It is necessary to know how to conduct the oral examination,where oral cancer occurs most frequently,what an early cancerous lesion may look like, andwhat to do when such a lesion is found. In addition to the early lesions of oral cancers, the oralmanifestations of neoplasms or abnormal growth of tissue,elsewhere in the body as well as the oral manifestationsof chemotherapy, can be recognized. Most oral cancers are related to tobacco and/or excessivealcohol use.

Additional risk factors include infection with HPV-16type, increased age >40, and sun exposure to the lips.2 Increasing incidence of oral cancers in adults youngerthan 40 suggests all patients, regardless of age or riskfactors, must be screened for oral cancer.

I. Location The most common sites for oral cancer are the lateralborders of the tongue, floor of the mouth, the lips, andthe soft palate complex.II. Appearance of Early CancerEarly oral cancer takes many forms and may resemble avariety of common oral lesions. All types need to be examinedwith suspicion. Five basic forms are listed here. White areas White areas vary from a filmy, barely visible changein the mucosa to heavy, thick, heaped-up areas of drywhite keratinized tissue. Fissures, ulcers, or areas of induration in a white areaare most indicative of malignancy. Leukoplakia is a white patch or plaque that cannot bescraped off or characterized as any other disease. Itmay be associated with physical or chemical agentsand the use of tobacco. Red areas Erythroplakia is a term used to designate lesions of theoral mucosa that appear as bright red patches or plaques. Lesions appear red, of velvety consistency, and maycoincide with small ulcers. Erythroplakia is a rare oral precancerous lesion that appear as bright red patches or plaques. Lesions appear red, of velvety consistency, and maycoincide with small ulcers. Erythroplakia is a rare oral precancerous lesion thatcannot be characterized as any specific disease.12 Ulcers Ulcers may have flat or raised margins. Palpation may reveal induration. Masses Papillary masses, sometimes with ulcerated areas, occuras elevations above the surrounding tissues. Other masses may occur below the normal mucosaand may be found only by palpation. Pigmentation Brown or black pigmented areas may be located onmucosa where pigmentation does not normally occur.27

Procedure For Determining when ASuspicious Lesion requires a biospy

Brush cytology toluidine blueDiffuse tissue reflectance laser-induced auto fluorescence 28

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Procedure For Determining when ASuspicious Lesion requires a biospy Diagnostic aids for minimally invasive detection of oralcancer include brush cytology and toluidine blue, diffusetissue reflectance, and laser-induced autofluorescence Alternatively, as designated by the dentist, a lesion maybe biopsied immediately and sent to a laboratory forevaluation. Biopsy confirmation is considered the goldstandard outcome.28

I. Exfoliative CytologyCytological SmearLiquid-Based CytologyOral Brush Cytology29

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Exfoliative cytology is a minimally invasive approachto obtain a cell sample for diagnosis of a suspiciouslesion.16 Exfoliated cells and the cells beneath (basal cells) areremoved by physical procedures such as surface scrapingor brushing, rinses, or saliva specimens.16,17 A number of studies have been conducted to evaluatethe different instruments used for obtaining cytologyspecimens. Basic requirements include: easy to use, minimal patientdiscomfort, and collects enough cells for evaluation.16 Basal cells are necessary to collect ribonucleic acidto improve diagnostic accuracy.16 Except for candidiasis, treatment cannot be determinedonly by smear technique results. After a positivesmear, a biopsy is needed for definitive diagnosis.A. Cytological Smear The cytologic smear is a diagnostic aid in which surfacecells of a suspicious lesion are removed for microscopicevaluation by noninvasive means such as a spatula orbrush. Cytology is useful for identifying Candida albicans organismsin patients with suspected candidiasis (moniliasis). Limitations of smear technique include the following: The smear detects only surface lesions. It is difficult or impossible to scrape deep enough toobtain representative cells from a heavily keratinizedlesion. Because research has shown that the smear techniqueis not diagnostically reliable (there can be falsenegatives, which turn out to be positive biopsies),a negative report cannot be considered conclusive.16B. Liquid-Based Cytology The specimen and collection device are placed in a liquidpreservative to create a suspension of cells.16 The sample is then mailed to a laboratory for analysis.C. Oral Brush Cytology Brush cytology has grown in popularity in recent years. Special brushes are used to penetrate the lesion and collecta sample that includes both surface and basal cells. The sample is then mailed to a laboratory for analysis. Despite the popularity of the brush cytology, the conventional smear cytology has been shown to have ahigher specificity and be less expensive.1729

II. SpectroscopyLaser-Induced AutofluorescenceVELscope

Diffuse Reflectance Spectroscopy30

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A. Laser-Induced AutofluorescenceSpectroscopy Laser-induced autofluorescence spectroscopy, such asthe VELScope, uses specific wavelengths of light tocause cells in oral lesions to fluoresce. The accuracy was 95.9% in detection of possible malignantlesions.17 Limitation: Not effective for lesions on the lateral anddorsal tongue or vermillion border of the lip becausenormal mucosa in these areas has a fluorescent spectrumsimilar to malignant cells.B. Diffuse Reflectance Spectroscopy Diffuse reflectance spectroscopy uses a fiber-optic probeto direct light to the suspicious lesion. Malignant cells scatter light differently than normalcells and this difference is measured.17 This method is 96.5% accurate in identifying possiblemalignant lesions and the most accurate noninvasivemethod.30

III. Biopsy Indications for biopsy Pathology report Class I : NormalClass II : Atypical, but not suggestive of malignant cells.Class III: Uncertain (possible for cancer)Class IV: Probable for cancer.Class V: Positive for cancer

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Biopsy is the removal and microscopic examination of asection of tissue or other material from the body for thepurposes of diagnosis. A biopsy is either excisional , when the entire lesion isremoved, or incisional , when a representative sectionfrom the lesion is taken. Considered the gold standard in oral cancerdiagnosis.23 Indications for biopsy Any unusual oral lesion that cannot be identifiedwith clinical certainty must be biopsied. Any lesion that has not healed in 2 weeks is consideredsuspicious for malignancy until proven otherwise. A persistent, thick, white, hyperkeratotic lesionand any mass (elevated or not) that does not breakthrough the surface epithelium. Pathology report If the laboratory report from the pathologist indicatesClass III through Class V from a cytology smear, a biopsyis required. Class I: Normal. Class II: Atypical, but not suggestive of malignantcells. Class III: Uncertain (possible for cancer). Class IV: Probable for cancer. Class V: Positive for cancer31

DocumentationEvery detail of the oral examinationRecommendations for frequency of examReview of all lifestyle habitsProgress note of first maintenance appt. 32

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Documentation in the permanent record of a patientwho needed a biopsy (or smear) because of a questionablecancerous lesion will contain a minimum such as thefollowing: Every detail of the oral examination and follow-upprocedures with reports from consultants, laboratories,medical follow-up, and outcomes. Recommendations for the frequency of a complete oralexamination, at future dental hygiene maintenanceappointments. Review of all lifestyle habits that may provide a causefor such an oral lesion to appear in the first place withrecommendations for specific preventive methods. A progress note representing the patients first maintenanceappointment following the incident of the biopsyand learning the lesion was not cancerous may bereviewed in Box 12-3.32

Factors to Teach the PatientGuidance and supportSelf-examination monthlyDietary and nutritional influencesOral cavity reflects general healthWarning signs of oral cancer 33

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Reasons for a careful extraoral and intraoral examinationat each maintenance appointment. Guidance and support on tobacco cessation and provideappropriate referral. How to conduct self-examination monthly to watchfor changes in oral tissues and identify lesions that lastlonger than 2 weeks. Examination includes the face,neck, lips, gingiva, cheeks, tongue, palate, and throat.Any changes are reported to the dentist and the dentalhygienist. General dietary and nutritional influences on the healthof the oral tissues. Benefits of diet rich in fruits and vegetables. How the oral cavity tends to reflect the general health. The warning signs of oral cancer from the AmericanCancer Society13 including the following: A swelling, lump, or growth anywhere, with or withoutpain. White scaly patches, or red velvety areas. Any sore that does not heal promptly (within 2weeks). Numbness or tingling. Excessive dryness or wetness. Prolonged hoarseness, sore throats, persistentcoughing, or the feeling of a lump in the throat. Difficulty with swallowing. Difficulty in opening the mouth.33