Examination of the Oral Cavity

Eric T. Stoopler, D.M.D., FDSRCS, FDSRCPSProfessor of Oral Medicine

University of Pennsylvania School of Dental MedicineAttending, Division of Oral Medicine

University of Pennsylvania Health Systemets@upenn.edu

www.aaom.com

Disclosures

• Employment, University of Pennsylvania

• Executive Committee, American Academy of Oral Medicine

• Board of Trustees, American Academy of Oral Medicine

• Textbook preparation, Elsevier, Inc.

• Monograph preparation, Metropolitan Life Insurance Co.

• Course Director, Coursera Online Learning Platform

• Honoraria, Continuing Education

• Become familiar with intraoral and extraoral examination

techniques

• Describe how to document lesions of the oral cavity

• Generate an appropriate differential and working diagnosis

www.cancer.gov

Bruch JM, Treister NS. Eds. Clinical Oral Medicine and Pathology, 2nd Ed., Springer, 2017 Yasney JS, et al. Mt Sinai J Med 2012

• 60% of total mucosa

• Non-keratinized

• Lips, cheeks, alveolar

mucosa, ventral tongue,

floor-of-mouth, soft palate • 25% of total mucosa

• Keratinized

• Gingiva, hard palate

• 15% of total mucosa

• Papillae

• Dorsal tongueCruchley AT, Bergmeier LA. Structure and Functions of the Oral Mucosa. In: L.A. Bergmeier (ed.),

Oral Mucosa in Health and Disease, Springer International Publishing, 2018

Documentation of Oral Lesion(s)

A. Site

• Exact anatomical site(s) the lesion occupies

• Avoid colloquial / layman’s terms

• Ex: Right posterior lateral border of the tongue

Kahn MA, Hall JA (eds.), The ADA Practical Guide to Soft Tissue Oral Disease (2nd Ed.); John Wiley and Sons, 2018.

Documentation of Oral Lesion(s)

B. Morphology

Blisterform – contains fluid

• Vesicle - < 0.5cm

– serum / mucin

• Bulla - > 0.5cm;

– serum / mucin / blood

• Pustule – any size

– contains purulent exudate

Nonblisterform - solid

• Papule - < 0.5cm

• Nodule – 0.5cm - < 2cm

– Sessile – broad-based

– Pedunculated – stalk

• Tumor - > 2cm

• Plaque - > 0.5cm

– “pasted on”

Elevated – surface is above the normal plane of mucosa

Kahn MA, Hall JA (eds.), The ADA Practical Guide to Soft Tissue Oral Disease (2nd Ed.); John Wiley and Sons, 2018.

Documentation of Oral Lesion(s)

B. Morphology

Ulcer

• Number: solitary v. multiple (separate vs. coalesced)

• Outline: regular v. irregular

• Margins: raised v. smooth

• Depth: superficial v. deep

• Diameter: 0.5cm (< or >)

• Scarring / atrophy / pitting / pouching may be present

Depressed – surface is below the normal plane of mucosa

Kahn MA, Hall JA (eds.), The ADA Practical Guide to Soft Tissue Oral Disease (2nd Ed.); John Wiley and Sons, 2018.

Documentation of Oral Lesion(s)

B. Morphology

Macule / Patch (except dorsolateral tongue)

Flat lesion of abnormal color

Macule: < 1.0 cm

Patch: > 1.0 cm

Dorsolateral tongue (Depapillation)

Mimics depressed lesion

Flat – surface is level with the normal plane of mucosa

Kahn MA, Hall JA (eds.), The ADA Practical Guide to Soft Tissue Oral Disease (2nd Ed.); John Wiley and Sons, 2018.

Documentation of Oral Lesion(s)

C. Color

• White

• Pink

• Red

• Red and white

• Blue

• Purple

• Gray

• Yellow

• Brown

• Black

• Translucent

Kahn MA, Hall JA (eds.), The ADA Practical Guide to Soft Tissue Oral Disease (2nd Ed.); John Wiley and Sons, 2018.

Documentation of Oral Lesion(s)

D. Size

• Measured by greatest

dimension in length and

width

• Expressed in metric units

(e.g. cm)

E. Consistency

• Fixed

• Freely moveable

• Indurated

• Firm, doughy, rubbery

• Soft

• Fluid, fluctuant, rebounding

Kahn MA, Hall JA (eds.), The ADA Practical Guide to Soft Tissue Oral Disease (2nd Ed.); John Wiley and Sons, 2018.

Differential Diagnosis

• Generated by patient history and physical exam findings

• Most likely dx (working dx)→ least likely dx

• Definitive dx (diagnostic test results + clinical exam findings)

• Dx algorithms

– Etiology (e.g. infectious vs. immune-mediated)

– Clinical appearance (e.g. white vs. red)

– Location (e.g. tongue vs. hard palate)

– Clinical behavior (e.g. localized acute vs. multiple chronic)

Idahosa CN, Kerr AR. Clinical Evaluation of Oral Diseases. In: Contemporary Oral Medicine, 2017

Idahosa CN, Kerr AR. Clinical Evaluation of Oral Diseases. In: Contemporary Oral Medicine, 2017

Clin

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The Concise Oral Examination

www.nidcr.nih.gov

Conclusions

• Develop a consistent approach to physical examination

• Appropriately document lesions of the oral cavity

• Develop an appropriate differential and working diagnosis

based on medical history and physical examination

findings

Thank You

• www.cancer.gov

• Bruch JM, Treister NS. Eds. Normal anatomy. In: Clinical Oral Medicine and Pathology, 2nd Ed., Springer, 2017

• Yasney JS, Herlich A. Perioperative dental evaluation. Mt Sinai J Med 2012; 79: 34-45.

• Cruchley AT, Bergmeier LA. Structure and Functions of the Oral Mucosa. In: L.A. Bergmeier(ed.), Oral Mucosa in Health and Disease, Springer International Publishing, 2018

• Kahn MA, Hall JA (eds.), Soft Tissue Head and Neck Pathology: Description and Documentation. In: The ADA Practical Guide to Soft Tissue Oral Disease (2nd Ed.); John Wiley and Sons, 2018.

• Idahosa CN, Kerr AR. Clinical Evaluation of Oral Diseases. In: Farah CS, et al. (eds.) Contemporary Oral Medicine; Springer International Publishing AG 2017; DOI 10.1007/978-3-319-28100-1_3-1.

• www.nidcr.nih.gov

References