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Intra-Oral Assessment for the NP: Treat? Or Refer?Jonathan Lang, DDS

Learning Objectives Following this presentation the learner will

be able to : Perform a complete oral assessment Identify normal and abnormal assessment

findings Identify normal assessment findings that

may be treated by HCPs Identify oral assessment findings that require

referral

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Purpose of the oral exam Cancer

30,000 new cases/year in US, over 8,000 deaths

Early detection increases survival rate 5 year survival rate = 50% Methods to treat are disfiguring

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Purpose of the oral exam Non-cancerous pathology

Periodontal disease Pre-cancerous lesions Dental decay (carious lesions) Temporomandibular joint dysfunction Parafunction including bruxism

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The 90 second oral cancer exam The extra-oral

assessment includes an inspection of the face, head and neck

Note any asymmetry or lesions on the skin. Such as crusts, fissuring and growths.

The regional lymph nodes in the submandibular and neck areas should be bilaterally palpated to detect any enlarged nodes

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The 90 second oral cancer exam Only tools required are adequate light, a 2x2

gauze and a mouth mirror 7 basic steps

Lips Labial mucosa Buccal mucosa Gingiva and alveolar ridges Tongue Floor of mouth Palate

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The 90 second oral cancer exam Lips

Note color texture and any abnormalities

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The 90 second oral cancer exam Labial mucosa

Note color, texture and any abnormalities

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The 90 second oral cancer exam Buccal mucosa

Note pigmentation, color changes, texture and any other abnormalities

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The 90 second oral cancer exam Gingiva and alveolar

ridges Again, note color,

pigmentation changes, texture, or any other abnormalities

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The 90 second oral cancer exam Tongue

Examine dorsum, lateral aspects, and ventral surface

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The 90 second oral cancer exam Floor of mouth

Visually inspect for swellings, color changes, texture

Wiping floor dry with gauze can aid in visualization

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The 90 second oral cancer exam Floor of mouth

Bimanually palpate the floor of the mouth for any abnormalities

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The 90 second oral cancer exam Palate

Inspect hard and soft palate with the mirror

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The 90 second oral cancer exam Points to remember

Most oral cancers are located on lateral aspects of tongue, floor of mouth and lips

Interview patient, if lesion has been present more than 2 weeks, refer for appropriate biopsy and treatment

Follow up to ensure a definitive diagnosis Remove all removable prostheses before

starting exam

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Extra-oral exam Sinuses Parotid glands Thyroid gland Lymph nodes Temporomandibular joints Muscles of mastication Cranial nerves

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Non-cancerous pathology Vesiculo-Bullous diseases

Herpes including Primary Herpetic Gingivostomatitis

Hand, foot, and mouth disease Epidermolysis bullosa

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Non-cancerous pathology HSV I

Self limiting Primary herpetic

gingivostomatisis Usually occurs in

children under 5

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Hand, foot and mouth Painful ulcers

preceded by vesicles on hands, feet, and oral mucosa, usually occurs in children

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Epidermolysis bullosa

Primarily a skin disease but oral lesions are often present

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Ulcerative conditions Squamous cell

carcinoma Indurated, non painful

ulcer with rolled margins

Most common on lateral tongue and floor of mouth

Males 2x higher than females

Clinically may be a white or red patch or mass

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White lesions Leukodema Hyperkeratosis Solar Cheilitis Leukoplakia Hairy Tongue Geographic Tongue Lichen Planus Candidiasis

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Leukodema 50% of whites and

90% of African Americans affected

Uniform opacification of buccal mucosa bilaterally

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Hyperkeratosis Asymptomatic

white patch usually from chronic irritation

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Solar Cheilitis Lower lip caused by

UV light

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Leukoplakia Asymptomatic white

path Cannot be wiped off May be related to

alcohol or tobacco use

5% are malignant, 5% become malignant

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Hairy Tongue Elongation of

filiform papillae of tongue

Improved oral hygiene can decrease

Benign but may be cosmetically objectionable

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Geographic Tongue White annular

lesions with atrophic red centers

Pattern migrates over dorsum of tongue

Common finding

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Lichen Planus Bilateral white striae Seen in middle age Buccal mucosa most

commonly affected with lesions occasionally on tongue, gingiva and palate

Usually treated with steroids

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Candidal Infections Painful elevated

plaques can be wiped off leaving a bleeding surface

Associated with: Poor oral hygiene Systemic antibiotics Systemic diseases Treated with anti-

fungals

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Pigmentations of Oral Tissues Normal pigmentation Amalgam tattoo Melanoma

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Normal pigmentation

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Amalgam tattoo

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Melanoma Malignancy of

pigmentary system

Oral melanomas may appear on palate and gingiva

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Gingival swellings Parulis

Usually occurs on buccal gingiva of children

Caused by periodontal condition or abscessed tooth

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Exostosis Bony hard

nodules covered by mucosa

Normal and cause is unknown

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Generalized hyperplasia Usually asymptomatic Often caused by

dilantin, nifedipine, hormone imbalance, leukemia

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Lip and Mucosa Swellings Mucous retention cyst

Solitary Asyptomatic Caused by blockage

of salivary gland duct Treated by excision

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Traumatic Fibroma Firm Represents

hyperplastic scar Non-malignant

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Diseases of the Teeth Erosion Attrition Food impaction Supernumerary teeth Fractures Pulp exposure Super eruption Abrasion Caries Calculus

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Erosion Typically

caused by acids Sucking on lemons,

excessive carbonated beverages, acid reflux, vomiting

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Attrition/Abrasion Most common

cause is bruxism or grinding

Typically an acid component in cases this severe

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Food Impaction Can occur where

teeth do not contact neighboring teeth

Leads to periodontal problems and eventual tooth loss

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Supernumerary Teeth Teeth present above

the normal 32 (including 3rd molars)

Usual treatment is extraction

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Fractures Typically caused

by trauma Frequently young

children Treatment

depends whether fracture enters the pulp

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Pulp exposure Dental trauma

can lead to exposure of the nerve

Treatment is an extraction or root canal therapy

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Super eruption Teeth that have

no opposing tooth in the arch will slowly erupt out of the dental alveolus

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Abrasion Typically caused

by excessive use of an oral hygiene device

Destruction can be rapid once it reaches softer underlying dentin

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Dental Caries Caused by Strep

mutans Once tooth structure

is lost, must be restored by a dentist

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Baby Bottle Caries Ask if parent puts

child to bed with juice or milk

Typically treated with stainless steel crowns to maintain teeth until permanents erupt

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Calculus Typically forms on

lingual of lower incisors due to proximity to sublingual salivary gland

Must be scaled and maintained by DDS

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Disease of the supporting structures of teeth Periodontal disease Abscesses

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Periodontal Disease Bacterial byproducts

lead to immune response that causes inflammation and subsequent bone loss around teeth

Treatment involves gross debridement of teeth

May involve periodontal surgery to access teeth for cleaning and antibiotic therapy

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Abscesses Can be buccal as in the

image Also can be located

palatal, sublingual, buccal, and submandibular

Can also penetrate into spaces of lower face causing a diffuse and life threatening infection –Ludwig’s Angina

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Abscesses Typically treated

emergently with incision and drainage and an extraction or root canal if dental in origin

Submandibular space infections require an extra oral approach

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Temporomandibular Joint Disorders

Typically caused by internal derangement of the articular disk

Present with and without reduction of the dislocated disc

Other causes include adhesions within the disc capsule

Internal derangements can cause a closed lock of mandible

Open lock is caused by a dislocation of the mandible itself, anterior of articular eminence

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Grinding / Bruxing Can cause significant premature wear on

the teeth Can cause fractures of teeth or existing

restorations Patient may complain of soreness in

masseter muscle area in the morning May complain that teeth are sore in the

morning

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Bruxism Round areas in cusp

tips of teeth are wear facets

Patient has worn through enamel into softer dentin, causing the cupping

Most common treatment is a night guard

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Non-pathologic Dental Findings These are non-pathologic but may

warrant a referral to dentist for evaluation Significant Class II or III occlusions Crossbites Thumb sucking Severe crowding Congenitally missing teeth Significant open bites

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Posterior crossbite

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Anterior crossbite

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Thumb/digit habits Much of open bite

will typically relapse once habit is ceased

If not, can usually be corrected orthodontically

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Severe crowding

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Congenitally missing teeth

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Significant open bites Open bites that are progressive in adults

may be indicative of TMJ disorders

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References The Journal of the American Dental

Association November 2001 vol. 132 no. suppl 1 36S-40S

Oral Pathology: Clinical Pathologic Correlations. Regezi and Sciubba. 3rd

Edition.

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