EXAMINATION AND DIAGNOSTIC METHODS
Lesions -of the oral cavity and perioral areas must be identified and characterized so that specific therapy can lead to elimination of the lesion. When a lesion is discovered, seyeral important, orderly stepsshould be undertaken to identify and characterize it (Fig, 21-1), These ‘steps include
the’ health history, history of the specific lesion,clinical examination, radiographic examination, laboratory Investigation, and, if indicated, surgical procedures to obtain a specimen for pathologic examination.
When the patient or dentist’ discovers a lesion, the dentist must be careful how this information is discussed with the patient. The words lesion, tumor growth, and biopsy carry terrifyiling connotations to many patients
FIG.21-1 Decision tree for treatment of oral lesions.
The empathetic dentist can spare patients from anxiety and frustration by carefully wording the discussion of the lesion. It behooves the dentist to remember and make the patient aware that the vast majority of lesions discovered in the oral and maxillofacial area are benign.
The overall medical status of the patientis of paramount importance .when investigating .a lesion. An accurate health history and, if needed-a thorough clinical evaluation or ‘consultation with medical specialists are mandatory for two basic reasons: 1. The first reason is that a preexisting medical problem may affect or be affected by the dentist’s treatment of
the patien!: As outlined in Chapters 1 and 2, patients with certain medical conditions, such as congenital heart defects, coagulopathies, and hypertension, may require special precautions when any surgical treatment is required: Furthermore, surgical intervention may upset the delicate balance between health and disease in a poorly controlled diabetic or imrnunocompromised person.
When a lesion is discovered, it must be carefully examined for clues to its nature. Furthermore, a thorough examination of the areas around the lesion, including the regional lymph nodes, is mandatory. Once the examination is complete, adetailed description of the findings is placed in the patient’s chart, It is very helpful to draw the lesion in the chart or on a schematic of the oral cavity and perioral areas (Fig. 21-2). A description and illustration allow the dentist to follow the course of the lesion over time and to determine whether it is resolving or changing in nature.
The anatomic ‘locationof the mass. Lesions may arise from any tissue within the oral cavity, including epithelium, subcutaneous and submucosal connective tissue, muscle, tendon, nerve, bone, blood vessels, and salivary
glands. The dentist should ascertain as much as possible which tissues are contributing to the lesion. The exact anatomic location of the lesion should aid in this determination. For example. if a mass is present on the dorsum
of the tongue, the dentist must consider an epithelial, connective tissue, or muscle ‘Origin for the mass. Similarly, a swelling on the inner aspect of the lower lip” should prompt the dentist to include a salivary gland
etiology in the differential diagnosis. \ Vhcncver a lesion is discovered, the dentist should always try to elucidate the cause of the lesion based on its anatomic location. The role of trauma in the appearance of oral lesions
should always be entertained (and a search for a SOUTce
of trauma undertaken). Ill-fitting prosthetic devices, chronic cheek biting and other habits, sharp teeth, and so on are common causes of oral lesions. Periapical and periodontal dental pathologic conditions also cause a
high percentag e of oral lesions.
FIG. 21·2 Illustrations of eril cavity and perioral areas, which are useful for indicating size and location.
FIG. 21-2-cont’d For legend see page .0461
Physical Types of Lesions
Bulla (pI. bu’lae): Loculated fluid in ‘or under the
epithelium of skin or mucosa; a large blister
Crusts: Dried or clotted serum protein on the surface of .
skin or mucosa
Erosion: Superficial ulcer (i.e., excoriation)
Macule: Circumscribed area of color change without
Nodule: Large palpable mass, elevated above the
epithelial surface –
Papule: Small palpable mass, elevated above the epithelial
Plaque: Hat elevated lesiori; the confluence of papules
I Pustule: Cloudy or white vesicle, the color of.which
I results from the presence of polymorphonuclear leukocytes
Seal: Macroscopic accumulation of keratin
Ulcer: Loss of ~pi helium , .
Vesicle: Smalilocuiation of fluid in or under the epith Jm; a small blister
2. The overall physical character of the lesion. The lesion should be described in proper medical terminology, . because lay terminology is sometimes misleading, For example, a “swelling” may be interpreted in many ways. Box 21-1 lists the more common physical descriptions that are useful in describing oral pathologtc entities. A lesion’s physical characteristics should always be categorized as (at least) one of the several
types of lesions listed
3. The size and shape of the lesion. Accurate recordings of these two basic physical characteristics should be made for future reference.
4.. Single versus multiple lesions. The presence. and locitien of multiple lesions is an important diagnostic . sign. When multiple areas of ulceration are found within the mouth,.the dentist can beginto rank the differential diagnostic possibilities. It is unusual to find multiple areas of carcinoma in the mouth, whereas a vesiculobullous disease commonly presents
with such a pattern. Similarly’, an ulcerated lesion on the lip and tip of the tongue (the so-called kissing ulcers) may indicate an infectious process
whereby one iesion in fects the tissue with which it comes into contact.
5.· The surface of the lesion. The surface may be smooth, -lobulated, or irregular, If ‘ulceration’ is present, the characteristics of the ulcer base should be recorded. Ulcer beds can be smooth; full of granulation tissue;
covered with a slough, membrane, or scab; or fungating, such as is seen with-some malignancies.
6. The colorof the lesion. The color or colors are an important consideration. A bluish swelling that blanches on
pressure m y indicate a vascular lesion, whereas a . bluish lesion that does not blanch may. indicate a mucus-containing lesion. A pigmented lesion of the oral mucosa may carry more importance than a lesion of normal ·color. An erythematous lesion may be more qminous than a white lesion. Some.lesions may have’ more than one COlor, and this should be noted in
detail. Frequently, inflammation is superimposed on areas of the lesion because of mechanical trauma or ulceration, which gives a varied plcture from one time
.to the next.
7. The sharpness of the boundaries of the lesion. If a mass
is present, is it fixed to surrounding deeper tissues or
is it freely movable? The determination of the boundaries
will aid in esrablishing whether the mass is fixed
to bone; arising from the bone and extending into
soft tissues, or of an infiltrating nature. The same
applies to an ulceration: however, a description of
FIG. 2JJ A, Anatomic lCX:lIti9l1 of cervlcotaclal lyrnph nodes
of the margfns, The margin of an ulcer may be flat,rolled, .raised, or everted. The.,amsisteno: o(the lesion to palpation. The consistency of lesions is described as soft, as in the case of a
lipoma; firm, whichis the consistency of a fibroma;
or hard, as in the’ case of an osteoma or tori. Indurated
simply ‘means firm or hard.
9. Presence of ttuctuation. Fluctuation is the term given to
a wavelike motion felt onpalpatmg a mass or cavity
with nonrigid walls, which contains fluid. This is a
valuable physical sign,’ because it- usually indicatesfluid
within the mass. It ,can be e~y palpating
with two.or more fingers in a’rhythmic fashfon, such .
tha t- as one ‘finger. exerts pressure, the othe-r finger
feels the impulse transmitted through the fluid-filled
10: Presence of pulsation. Palpation of a mass may reveal. a
pulsatile quality, which indicates a large vascular component. This IS especially important in ~ny lesions. A
thrill is the name given ‘tb the palpable vibration
accompanying a vascular murmur or. pulsation. If a
thrill is palpable, auscultation with a stethoscope may
reveal a briiit,or audible murmur: Lesions with palpa- ble f~riiIs or audible bruits should’ bereferred to a specilis( tor’ treatment, because life-threatenlng.hemor-
rhage can .artse when biopsy is attempted.
11. Lymph node examination. No evaluation of an oral
lesion Is complete without a thorough regional lymph
node examination. Before any biopsy procedure, it is
particularly important to perform a thorough examination
of the regional lymph nodes. Sometimes lymphadenitis
develops in regional nodes after a biopsy
procedure. The enlargement of these nodes as a result
of inflammation may pose a problem in differentiat-
, Inglnfectlon or inflammation from metastatic spread
of tumor. Fig:2I’~3 illustrates the important and more
common lymph nodes in the maxillofacial region. ‘
‘When recording findingsthe fo!Iowing five characteristics
should routinely be included: (1) location; (2) size, -e :»
preferably giving the diameter in centimeters; (3) tenderness
(painful versus nonpainful); (4.) degree of fixation
(movable,’ matted, or fixed); and (5) texture (soft, hard, or
firm). ‘Normal- lymph nodes are not palpable. However,
nodes enlarge with inflammation and may be palpable as
.a result. Cervical nodes up to 1 cm in diameter are almost
always felt in the cervical region of children up to age 12
and are not an abnormal finding. The standard examination
of the: lymph nodes requires only simple inspectlon
and palpation. It is always useful to compare sides by using
the middle three fingers for palpation. This examination is
methodic and proceeds downward asJollows: (1) occipital
and postauricular; (2) submandibular and submental; (3)
” anterior cervical triangle (i.e., upper end of deep cervical
fLG. 21-4 A, Radioqraphic appearance of cyst (arrows). :\ute penpheral condensmg osteitis around radiolucent center. B, Radiographic appearance of bone destruction by malignancy (arrows). Sq~amous cell carcinoma has eroded into mandible. Note ragged appearance
chain); J..f) downward along sternocleidomastoid muscle (i.e., superficial cervical nodes); 15) posterior triangle t i.e., lower end of deep cervical chain); and (6) supraclavicular. Movements during palpation should be slow and gentle: the fingers move across each arc.i examined in vertical and horizontal directions followed by rotary motion.
Radiographs are useful as diagnostic adjuncts 1.0 the clinical examination and history of lesions within or adjacent to bone. When lesions within the sort tivsues arc proximal to ‘bone, radiographs .may elucidate whether the lesion is causi ng an osseous reaction or erodillg into the bone. ,\
\ ;!fIN\’ of radiographic projections may-he used, depending 01 ::,~, anatomic location of the lesion. Most pathologic UlIlLI,tJ(‘ll\ 01 the mandible or maxilla can be satisfactorily dvmonvtrated by routine radiog.raplly, but, occasionally, . pccial imaging techniques are required to elucidate some particular facet of the case under investigation.
Indications for Biopsy
~ Any .lesion that persists for more than 2 weeks with
no apparent cause . .
•. Any inflammatory lesiofl that does not respond to-
. local treatment after 10 to 14 days (after removing
• Persistent hyperkeratotic changes in surface tissues .
• Any persistent tumescence, either vi~ or palpable
beneath relatively normal tissue. .
• Inflammatory changes of unknown cause that “persist
for long periods :,.
• Lesions that interfere with local function (e.g;, fibfoma)
• Bone lesions not specifiCilllyidentified by clinical and
. radiographic findings .
• Any lesion that has the characteristics of malignanCy.
Characteristics of Lesions that Raise Suspicion of Malignancy
Erythroplasia: Lesion is totally red or has a speckled red
an(! .white’ appearance
Ulceration: Lesion is ulcerated or presents as.an ulcer:
Duration: Lesion has persisted more than 2 weeks
Growth rate: Lesion exhibits rapid growth
Bleedlhg: lesion bleeds on gentle manipulation
Induration: Lesion and surrounding tissue is firm to the
FiXation: lesion feels attached to adjacent structures
extent of the cyst. Radiopaque probes (i.e., needles) can be used to localize a foreign object ‘or pathoiog.ic· entity.
Several oral lesions may be manifestations of systemic diseases. For instance, multiple lytic lesions and loss of lamina dura bone suggest the possibility .of hyperparathyroidism. Serum levels of calcium, phosphorus, and alkaline phosphatase should identify this metabolic abn ormality. A patient with multiple radiolucencies of the jaws or other bones may also have multiple myeloma. Serum protein analysis can be useful for identifying this drsease process.
Surgical Specimen for Pathologic Examination
Once the ‘preceding s~ps have been accomplished, the ‘dentist should compilea differential diagnosis. In most instances the data obtained from the history and the clinical and radiographic examinations provide enough
information for a tentative diagnosis. Lesions that appear traumatic in origin may. be initially’ treated nonsurgically by elimination of any continued source of irritation (e.g., relieve or’ reline dentures, smooth a ‘sharp tooth or appliance). Observation For 10 to 14 days will verify the presumptive diagnosis in these cases; that is, the lesion should heallf trauma is a cause.