1: Introduction

1

Introduction

Oral medicine has been defined as being ‘concerned with the oral health care of patients with chronic recurrent and medically related disorders of the mouth and with their diagnosis and non-surgical management’. Oral diseases can affect people of any background, gender or age.

Children are usually most liable to dental caries and the sequelae of odontogenic infections, and to acute viral infections, but oral diseases are generally more common in adults, especially older people or people with systemic disease. Immunocompromised individuals are especially prone to oral disease, and also to serious outcomes.

Factors predisposing to oral disease may include:

• Genetic predisposition: prominent especially in autosomal dominant conditions
• Systemic disease: including mental health issues
• Lifestyle habits: including poor oral hygiene and/or use of tobacco, alcohol, betel and recreational drugs
• Iatrogenic (doctor-induced) influences: such as the wearing of oral appliances; radiation therapy; transplantation procedures; drugs
• Nutrition: malnutrition and eating disorders.

Dangerous conditions

Many oral medicine conditions are recurrent or chronic and some are serious, with considerable associated morbidity (illness), often affecting the quality of life (QoL), and some are potentially lethal.

Conditions that are potentially dangerous or have a high mortality include disorders such as pemphigus, cancer and chronic infections such as HIV/AIDS, tuberculosis or syphilis (all of which may be lethal). Other conditions have a high morbidity (incidence of ill health), and these include temporal arteritis (cranial or giant cell arteritis), pemphigoid or Behçet syndrome (which can lead to blindness), trigeminal neuralgia and facial palsy (which may signify serious neurological diseases), and potentially malignant oral disorders such as leukoplakia, lichen planus and submucous fibrosis.

It is important to refer or biopsy a patient with any unusual lesion, especially a single lesion persisting 3 or more weeks (which could be a cancer), or if there are typically multiple persisting ulcers when a vesiculobullous disorder such as pemphigus is suspected (since this is potentially lethal).

Changes that might suggest malignant disease such as cancer could include any of the following persisting more than 3 weeks:

• A sore on the lip or in the mouth that does not heal
• A lump on the lip or in the mouth or throat
• A white or red patch on the gums, tongue, or lining of the mouth
• Unusual bleeding, pain, or numbness in the mouth
• A sore throat that does not go away, or a feeling that something is caught in the throat
• Difficulty or pain with chewing or swallowing
• Swelling of the jaw that causes dentures to fit poorly or become uncomfortable
• A change in the voice, and/or
• Pain in the ear
• Enlargement of a neck lymph gland.

If in any doubt – refer the patient for a second or a specialist opinion.

History

The history gives the diagnosis in the majority (possibly about 80%) of cases. Important questions to answer include, what is this chief or primary complaint (Complaining of [CO] or Chief Complaint [CC]) and what is the history (History of the Present Complaint [HPC]) – is this:

• The first episode?
• Persistent or recurrent?
• Changing in size or appearance?

and are there:

• Single or multiple lesions/symptoms?
• Specific or variable symptoms?
• Extraoral lesions?

The Relevant Medical History (RMH), Family History (FH) and Social History (SH) should be directed to elicit a relevant history in terms of a range of aspects. One way to remember all this is by the acronym GSPOT, MED, RAGES:

• Genetics: family history?
• Social history?
• Pets?
• Occupation?
• Travel history?
• Medical history/medications?
• Eating habits?
• Drugs and habits? (drugs of misuse; tobacco; alcohol; betel; artefactual [this means self-induced, or factitial])
• Respiratory features?
• Anogenital features?
• Gastrointestinal features?
• Eye features?
• Skin, hair or nail features?

Additionally, other aspects are needed in relation to complaints specific to different systems, as detailed below.

History related to dental problems

The history related to dental (tooth) problems should also include at least:

• date of onset of symptoms
• swelling details, such as duration and character
• pain details, such as duration, site of maximum intensity, severity, onset, daily timing, character, radiation, aggravating and relieving factors, relationship to meals and associated phenomena
• mouth-opening restriction
• changes in the occlusion of the teeth
• hyposalivation details.

Disorders that affect the teeth may appear to be unilateral, but the other teeth should always be considered, and it is important to consider the possibility of related systemic disorders, especially those affecting:

• musculo-skeletal/connective tissue
• the neurological system (e.g. seizures)
• nutrition (eating disorders such as bulimia).

History related to mucosal problems

The history related to mucosal problems should also include at least:

• date of onset of symptoms
• lesional details, such as duration and character
• pain/discomfort details, such as duration, site of maximum intensity, severity, onset, daily timing, character, radiation, aggravating and relieving factors, relationship to meals and associated phenomena
• mouth-opening restriction.

Disorders that affect the mucosa may appear to be unilateral, but all the other oral mucosa should always be examined, and it is important to consider the possibility of related systemic disorders, especially infections, and those affecting:

• the haematopoietic system (e.g. anaemia or leukaemia)
• the gastrointestinal tract (e.g. Crohn disease)
• the skin and/or anogenital (e.g. lichen planus) or conjunctival or other mucosae (e.g. erythema multiforme)
• nutrition (disorders such as hypovitaminosis).

History related to salivary problems

The history related to salivary problems should also include at least:

• date of onset of symptoms
• swelling details such as site, duration and character, and relation to meals and whether enlarging
• quality and quantity of saliva, both observed and perceived, and details of any speech difficulties, dysphagia or taste alterations
• pain details, such as duration, daily timing, character, radiation, aggravating and relieving factors, relationship to meals and associated phenomena
• mouth-opening restriction

• history of dry eyes or dryness of other mucosa
• personal or family history of arthritis
• occupation, such as glass blowing or trumpet playing, which might introduce air into the gland (pneumoparotid).

Disorders that affect the salivary glands may appear to be unilateral, but the other glands should always be considered, and it is important to consider the possibility of related systemic disorders, especially those affecting:

• lachrymal and other exocrine glands (e.g. Sjögren syndrome)
• endocrine glands (e.g. diabetes)
• hepatobiliary system (e.g. alcoholic cirrhosis may underlie sialosis)
• connective tissues (e.g. rheumatoid arthritis or systemic lupus erythematosus).

History related to jaw problems

The history should also include:

• date of onset of symptoms
• precipitating factors (e.g. trauma)
• swelling details, such as duration and character
• pain details, such as site of maximum intensity, onset, duration, severity, daily timing, character, radiation, aggravating and relieving factors, relationship to meals and associated phenomena
• mouth-opening restriction
• history of dry eyes or dryness of other mucosa
• personal or family history of arthritis.

Disorders that affect the jaws or temporomandibular joint (TMJ) may appear to be unilateral, but the other areas should always be evaluated, and it is important to consider the possibility of related systemic disorders, especially infections and those affecting:

• bones (e.g. osteoporosis)
• joints (e.g. osteoarthritis)
• connective tissues (e.g. rheumatoid arthritis).

History related to pain and neurological problems

The history should also include at least (Box 1.1):

 

Box 1.1   Characteristics of pain (SOCRATES)

Site
Onset
Character
Radiation
Associated features
Time course
Exacerbating and relieving factors
Severity
• date of onset of symptoms
• symptom details, such as duration and character, referred pain

• pain details, such as duration, daily timing, character, radiation, aggravating and relieving factors, relationship to meals, and associated phenomena
• movement disorders
• sensory loss, including visual changes.

Disorders that affect the neurological system may appear to be unilateral, but the cranial nerves and neurological system should always be considered, and it is important to consider the possibility of related systemic disorders, especially those affecting the cardiovascular system (e.g. thromboembolism).

Examination

Careful examination is crucial and should include at the very least those extraoral areas readily inspected, such as (usually) the head and neck, and hands – with due consideration for culture.

Extraoral examination

Extraoral examination should include assessment of general features such as:

• anxiety or agitation
• appearance
• behaviour
• breathing
• communication
• conscious level
• movements

• posture
• sweating
• temperature
• wasting
• weight loss or gain

and careful inspection of the face for:

• facial symmetry
• facial colour – for pallor (e.g. fear, anaemia) or
• facial erythema (e.g. anxiety, alcoholism, polycythaemia) or rashes (e.g. infections, lupus) or other lesions (e.g. basal cell carcinoma)
• facial swellings – for soft tissue or salivary gland swellings (e.g. allergies, infections or inflammatory lesions), enlarged masseter muscles (masseteric hypertrophy) or bony enlargement
• fistulas or sinuses (which may be odontogenic in origin)
• pupil size (e.g. dilated in anxiety or cocaine abuse, constricted in opioid abuse).

Neck examination is mandatory, especially examination of cervical lymph nodes. Lesions in the neck may arise mainly from the cervical lymph nodes, but also from the thyroid gland, salivary glands and heterotopic salivary tissue, or from skin, subcutaneous tissues, muscle, nerve, blood vessels or other tissues.

Lesions arising from the skin can usually be moved with the skin and are generally readily recognizable.

Jaws

The jaws should be palpated to detect swelling or tenderness. Maxillary, mandibular or zygomatic deformities, fractures or enlargements may be more reliably confirmed by inspection from above (maxillae/zygomas) or behind (mandible).

Following trauma, all borders and sutures should be palpated for tenderness or a step deformity (at the infraorbital rim, the lateral orbital rim, the zygomatic arch and the zygomatic buttress intraorally).

The jaw joints (TMJ) should then be examined by inspecting:

• facial symmetry
• facial and intraoral discolouration and swelling (haematoma, ecchymoses, laceration)
• jaw opening and movements

and by palpating the bones, main masticatory muscles (temporalis, masseters and pterygoids), and TMJ – using fingers placed over the joints in front of the ears, to detect pain, or swelling.

Finally, the dental occlusion should be examined.

The neurological system

Cranial nerve examination may also be needed (Table 1.1), by inspecting:

Table 1.1

Cranial nerve examination

Nerve Test/examination/consequence of lesion
Number Name
I Olfactory Smell
II Optic Visual fields
Visual acuity
Pupils equal reactive to light and accommodation (PERLA)
Fundoscopy
III Oculomotor Eye movements
IV Trochlear Diplopia
V Abducens Nystagmus
VI Trigeminal

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Related posts:

  1. 9: Referral for specialist advice
  2. 8: Management protocols for patients with oral diseases treated in primary care settings
  3. 6: Diagnosis
  4. 7: Investigations
  5. 3: Differential diagnosis by site
  6. 2: Differential diagnosis by signs and symptoms

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Jan 12, 2015 | Posted by in Oral and Maxillofacial Pathology | Comments Off on 1: Introduction

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